Disparities in the Treatment of the LGBTQ Population in Chronic Pain M | JPR – Dove Medical Press
It is becoming increasingly important to recognize discrepancies in the care of lesbian, gay, bisexual, transgender, or queer (LGBTQ) patients in all medical subspecialties, and in pain management there is no exception. The percentage of Americans aged 18 or older who identify as LGBTQ has risen from 4.5% in 2017 to 5.6% in 2020. One in six adults in Gen Z identify as LGBTQ.1
Unique Chronic Pain Needs
The LGBTQ population experiences unique needs regarding chronic pain management compared to the general population. Sexual minority adults experience more frequent functional limitations due to pain2 and are more likely to experience pain from multiple sites compared to heterosexual adults; headaches, migraines, abdominal pain, digestive complaints, back pain, shoulder/neck pain, and arthritis are more common in this population.2,3 Additionally, mostly heterosexual females and gay males are more likely than same-gender completely heterosexuals to have headaches, and mostly heterosexual and bisexual females are more likely to have muscle or joint pain. Compared to same-gender heterosexual males, gay males were more likely to report headaches.4
The relationship between depression and pain is well established. The prevalence of chronic pain in patients suffering from depression has been reported to be 51.8–59.1%,5–7 and depression is a risk factor for the onset of chronic pain.8,9 Furthermore, depression worsens prognosis in treating chronic pain,10,11 and comorbid pain and depression lead to more interference in activities of daily living, work, and social interactions.12 These conditions are strongly linked to each other and lead to worse outcomes when patients suffer from both.
The link between depressive disorders and the LGBTQ population is also well established. Sexual minority adults experience higher rates of depressive symptoms and disorders than heterosexual individuals.13 Sexual minority adolescents report a higher incidence of depression, anxiety, and increased suicidal behaviors than heterosexual adolescents.14 This population experiences high levels of institutionalized prejudice, social stress and exclusion, hatred and violence that contribute to an increased incidence of depression and anxiety, among other health problems. Increased drug and alcohol misuse also contribute to comorbid mental health disorders.15,16
Within the LGBTQ population, unique challenges and social stress are linked with high levels of depressive disorders. These mental health challenges produce a population with high levels of chronic pain, worse outcomes, and unique challenges in treating them.
Barriers to Care
The LGBTQ population faces challenges in access to healthcare. A larger portion of LGBTQ individuals lack access to health insurance and live in poverty than is the case in the general population.17 LGBTQ individuals are more likely to delay medical care or forgo it entirely.18 Reasons for avoiding healthcare include discrimination from health care providers and even denial of care.19,20 A 2015 study found that 33% of transgender individuals reported one or more negative experiences related to being transgender such as being refused treatment, being harassed or assaulted, or receiving incompetent care.21
Discrimination and receiving incompetent care are reasonable fears. Bias and lack of education of this population is common among healthcare providers. A study of medical students demonstrated that approximately half of the students reported having negative attitudes toward lesbian and gay people.22 Additionally, most medical schools and residency programs do not educate sufficiently on LGBTQ healthcare. In American and Canadian medical schools, an average of only 5 hours is spent on LGBTQ-specific content; many reported no such education at all.23
Education and cultural competency can improve outcomes for the LGBTQ population.24 A history of discrimination leading to socioeconomic challenges has led to barriers to utilizing healthcare which have created worse health outcomes. This population deserves better care, and it is our responsibility as providers to work to educate ourselves and examine possible biases we have that are contributing to barriers in care.
Discussion
Unique and unfortunate socioeconomic stressors have led to high amounts of comorbid mental health disorders and chronic pain in the LGBTQ population. This population is more likely than their heterosexual counterparts to report chronic pain in multiple sites causing functional limitations. Comorbidity with mental health disorders leads to worse prognoses in the treatment of chronic pain and more interference with relationships and activities or daily life. Therefore, special attention should be paid to the care of these patients and efforts should be made to improve access to care.
Provider education and dedication to improving cultural competency are measures that the medical community can take to help this population gain confidence in utilizing healthcare. Additionally, improving access to health insurance remains a necessary step. Through acknowledging the unique challenges and health problems of the LGBTQ, we can strive to better treat chronic pain and improve the quality of life of all of our patients. Our failure to do so would represent a violation of the bioethical principle of justice, and as the number of people acknowledging LGBTQ identification continues to increase, we can hardly afford to do so.
Disclosure
Dr Michael E Schatman serves as a research consultant for Modoscript. The authors report no other conflicts of interest in this work.
References
1. Jones JM LGBT identification rises to 5.6% in latest U.S. estimate; 2021. Available from: https://news.gallup.com/poll/329708/lgbt-identification-rises-latest-estimate.aspx.
2. Fredriksen-Goldsen KI, Kim HJ, Shui C, Bryan AEB. Chronic Health Conditions and Key Health Indicators Among Lesbian, Gay, and Bisexual Older US Adults, 2013–2014. Am J Public Health. 2017;107(8):1332–1338. doi:10.2105/AJPH.2017.303922
3. Case P, Austin SB, Hunter DJ, et al. Sexual orientation, health risk factors, and physical functioning in the Nurses’ health study II. J Womens Health. 2004;13:1033–1047. doi:10.1089/jwh.2004.13.1033
4. Katz-Wise SL, Everett B, Scherer EA, Gooding H, Milliren CE, Austin SB. Factors Associated with Sexual Orientation and Gender Disparities in Chronic Pain Among U.S. Adolescents and Young Adults. Prev Med Rep. 2015;2:765–772. doi:10.1016/j.pmedr.2015.09.011
5. von Knorring L, Perris C, Eisemann M, Eriksson U, Perris H. Pain as a symptom in depressive disorders. II. relationship to personality traits as assessed by means of KSP. Pain. 1983;17(4):377–384. doi:10.1016/0304-3959(83)90169-0
6. Lee P, Zhang M, Hong JP, et al. Frequency of painful physical symptoms with major depressive disorder in Asia: relationship with disease severity and quality of life. J Clin Psychiatry. 2009;70(1):83–91. doi:10.4088/jcp.08m04114
7. Agüera-Ortiz L, Failde I, Mico JA, Cervilla J, López-Ibor JJ. Pain as a symptom of depression: prevalence and clinical correlates in patients attending psychiatric clinics. J Affect Disord. 2011;130(1–2):106–112. doi:10.1016/j.jad.2010.10.022
8. Gureje O, Simon GE, Von Korff M. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92(1–2):195–200. doi:10.1016/s0304-3959(00)00483-8
9. Carroll LJ, Cassidy JD, Côté P. Depression as a risk factor for onset of an episode of troublesome neck and low back pain. Pain. 2004;107(1–2):134–139. doi:10.1016/j.pain.2003.10.009
10. Bair MJ, Robinson RL, Eckert GJ, Stang PE, Croghan TW, Kroenke K. Impact of pain on depression treatment response in primary care. Psychosom Med. 2004;66(1):17–22. doi:10.1097/01.psy.0000106883.94059.c5
11. Dworkin RH, Gitlin MJ. Clinical aspects of depression in chronic pain patients. Clin J Pain. 1991;7(2):79–94. doi:10.1097/00002508-199106000-00004
12. Ohayon MM, Schatzberg AF. Chronic pain and major depressive disorder in the general population. J Psychiatr Res. 2010;44(7):454–461. doi:10.1016/j.jpsychires.2009.10.013
13. Bostwick WB, Boyd CJ, Hughes TL, et al. Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. Am J Public Health. 2010;100:468–475. doi:10.2105/AJPH.2008.152942
14. Safren SA, Heimberg RG. Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. Safren S, Heimberg R. J Consult Clin Psychol. 1999;67(6):859–866. doi:10.1037/0022-006X.67.6.859
15. King M, McKeown E, Warner J, et al. Mental health and quality of life of gay men and lesbians in England and Wales: a controlled, cross-sectional study. Br J Psychiatry. 2003;183:552–558. doi:10.1192/bjp.183.6.552
16. Meyer IH. Prejudice, social stress and mental health in lesbian, gay and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674–697. doi:10.1037/0033-2909.129.5.674
17. Whittington C, Hadfield K, Calderon C. The lives and livelihoods of many in the LGBTQ community are at risk amidst COVID-19 crisis; 2020. Available from: https://www.hrc.org/resources/the-lives-and-livelihoods-of-many-in-the-lgbtq-community-are-at-risk-amidst.
18. Krehely J. How to close the LGBT health disparities gap. Center Am Progress. 2009;1:1–9.
19. Grant JM, Mottet LA, Tanis J. National Transgender Discrimination Survey Report on Health and Health Care. Washington DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2010.
20. Shires DA, Jaffee K. Factors associated with health care discrimination experiences among a National Sample of female-to-male transgender individuals. Health Soc Work. 2015;40(2):134–141. doi:10.1093/hsw/hlv025
21. National Center for Transgender Equality. The Report of the 2015 U.S. Transgender Survey: Executive Summary. James SE, et al. National Center for Transgender Equality; 2016
22. Burke SE, Dovidio JF, Przedworski JM, et al. Do contact and empathy mitigate Bias against gay and lesbian people among heterosexual first-year medical students? A report from the medical student CHANGE study. Acad Med. 2015;90(5):645–651. doi:10.1097/ACM.0000000000000661
23. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971–977. doi:10.1001/jama.2011.1255
24. Haviland KS, Swette S, Kelechi T, Mueller M. Barriers and Facilitators to Cancer Screening Among LGBTQ Individuals With Cancer. Oncol Nurs Forum. 2020;47(1):44–55. doi:10.1188/20.ONF.44-55