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2022 Namey/Burnett Preventive Medicine Writing Award third-place winner Krisdaniel Berreta, OMS-III, discusses how the intersection of being a member of the immigrant and LGBTQI communities can lead to poor health outcomes and outlines actions to address these issues.
Krisdaniel Berreta, OMS-IV | Edward Via College of Osteopathic Medicine – CarolinasSponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
Immigrant health has become a research topic of interest over recent years, and it is likely that this trend will continue. Today, immigrants comprise more than 15% of the United States population.1 It is projected that over the next several decades, the immigrant representation of the country will continue to increase.2 This raises a concern because it is known that access to resources—including healthcare insurance, preventive care and health benefits—are limited for undocumented immigrants.3,4 However, foreign-born adults who migrate into the country and who identify with the lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) population have not been extensively reviewed. It is already a challenge to determine the number of LGBTQI individuals within the United States currently, which raises the question of how an accurate estimation can be calculated of LGBTQI immigrants.5 Research shows that both populations suffer from health disparities individually, but enough research has not been done to determine the outcome of those who would be in the intersection of immigrant and queer identity. The LGBTQI immigrant population is a marginalized group at risk for chronic illness and needs interventions that would promote their longevity and health outcomes.
The LGBTQI and immigrant groups each have their own disparities; however, there are enough similarities that interventions and changes made moving forward could possibly benefit both groups. Those in the queer community are at higher risk of suicide, sexually transmitted diseases and mental health disorders.6,7 Undocumented immigrants are unique in that they lack access to health care due to barriers secondary to their undocumented status, thus predisposing them to often manageable conditions.4 When you narrow in on individuals who are both LGBTQI and an immigrant, there is a unique intersection of hardship and cumulative disadvantages that would be experienced.
Undocumented LGBTQI immigrants would not only face the immigrant challenge of accessing health care benefits, language barriers and the complex structure of the American healthcare system, but also the challenges and experiences that non-immigrant queer individuals would face.3,4 When intermixed, these two identities create a challenging situation that brings to light the importance of taking preventive measures to address the chronic health issues to which this specific group will be susceptible. Despite the clear need to make change, research shows that it is very difficult to identify and reach the population of queer older adults as is.
Estimating the number of adults who are queer is already a challenge in aging LGBTQI research due to national public health surveys not including questions that ask participants to identify their sexual orientation or gender identity.3,5 This creates a problem for researchers to obtain a sample, thus preventing a generalized understanding of the needs of this growing population. If this problem exists with LGBTQI U.S. citizens, it can be inferred that this issue would also extend to foreign-born immigrants who are undocumented and queer. Due to fears of deportation, and discrimination, as well as post-migration stressors, it is likely that LGBTQI immigrants would identify themselves neither as an immigrant nor part of the gay community out of fear of exclusion.
Many LGBTQI immigrants migrate to escape social and political exclusion from their home country, and it is unfortunate that they may continue to experience discrimination in the United States. It is already known that transgender individuals are at risk immediately when under the scope of immigration enforcement during migration. This is due to the policy of identifying individuals by their gender at birth, rather than the gender with which they identify.4 This disparity, among others, is likely to cause secondary effects to their health that would persist into adulthood and co-exist along other chronic conditions.6,7 Targeted prevention and intervention programs are needed as LGBTQI adult immigrants age, and there are interventions that can be implemented today by the medical community that could address these issues.
It can be argued that state and government policy need to be changed to address issues involving immigrants. Research shows how change in policy affects immigrant health outcomes and can promote stigmatization against this already oppressed and marginalized group, leading to increased rates of discrimination and fear of deportation.7 The same could be argued about LGBTQI-related policy and how the mental health of the queer community could be negatively impacted if new laws were passed that went against their rights, although more research needs to be conducted to confirm this. In order to address and help those who identify as both an immigrant and a member of the LGBTQI community, a simple and effective change can be implemented and started in the nation’s medical schools to prepare the future generation of physicians who will encounter this unique population.
Since it is known that the diversification of the country and the number of immigrants and LGBTQI adults will increase over time, matriculating medical students will encounter individuals who may belong to one or both groups. While current medical school curricula address the health issues of the heterosexual aging population, there is a lack of full coverage for the needs of the aging queer population. Although medical educators have called for more medical schools to implement changes to address LGBTQI-related health care, these topics are often limited to sexually transmitted diseases, mental health and methods for obtaining a patient’s sexual history.5,7,8 While this initiative is a significant step forward, there needs to be additional changes made that would address the disparities that an adult LGBTQI person would face, especially for those with a context of being foreign-born and having immigrated into the country. Research shows that the queer population’s experiences of violence and victimization can have long-lasting effects on not only the individual, but also the community as whole.6,8 Effort is needed to improve the very preventable outcomes of this unique LGBTQI immigrant population and the implementation of change to a medical school’s educational objectives is only the first step.
While updating educational objectives taught within classrooms of medical schools will likely bring awareness to the needs of the aging LGBTQI immigrant population, a significant and impactful change would be to expose medical students to this population early in their training. A recent study introduced the idea of medical schools hosting a senior community panel that would educate students on the issues that were unique to LGBTQI elders. Other ideas were to incorporate related facts into medical school system-based blocks, such as the differences in LGBTQI cardiovascular health compared to the non-LGBTQI population during a student’s cardiovascular course; or in an ethics course, the unique ethical dilemma of queer patients “choosing their family members,” instead of utilizing their immediate family for end-of-life support.9 In addition, another powerful means by which medical schools can implement needed interventions is to allow students to form LGBTQI student organizations that would foster and enhance the delivery of healthcare to these marginalized populations. It could also serve to educate osteopathic students on the unique requirements of a population that is very present in the country’s current demographics and is likely to increase moving forward. The principles of osteopathic medicine guide students to treat patients with the context of a person’s individual social and psychological needs. Osteopathic medical students carry the potential to address LGBTQI immigrant disparities, but the opportunity to provide this care is at risk if they are not introduced and taught the hardships this population faces and how their health is impacted long term.
There is value in prioritizing immigrant LGBTQI adult health. Whether each identity and their associated disparities and preventable conditions are viewed separately or collectively, both immigrant and LGBTQI populations will grow to represent a significant portion of the nation. More research is needed to better comprehend and identify the needs of these populations; however, it is clear that addressing these issues could reduce disease transmission and the costs associated with these conditions, improve the wellbeing of those affected and improve the livelihood of a representable and marginalized population.6,7 This work can begin with osteopathic students because from day one they are taught to deliver culturally competent care and the tenets of osteopathy in which they treat not only the person, but also the mind, body and spirit.
ACOFP is a community of current and future family physicians that champions osteopathic principles and supports its members by providing resources such as education, networking and advocacy, while putting patients first.