How Obamacare Is Failing Young Gay Men
When it comes to health care, young gay men are falling through the cracks
Emerging adulthood is a complex time for anyone. It ranges from late adolescence to one’s mid-twenties – ages when we are seeking to establish our identities in social contexts, and transition from childhood to the expectations and responsibilities of adulthood.
For young adults in sexual minorities, this age of transition can be especially fraught. Physical, emotional, cognitive and social development are coupled with the process of coming out and negotiating a sexual identity in a society that is still homophobic. Researchers consistently observe poor physical and mental health outcomes among gay and lesbian young adults, and these outcomes can be further exacerbated by both racism and poverty.
My own research on young men who have sex with men has found that they are not accessing basic primary care that can keep them healthy.
Young sexual minority men have difficulty accessing health care
Early adulthood is a complex time, and sexual minority young men may also have to contend with the confluence of illicit drug use, unprotected sexual behaviors and mental health burdens – all of which can put them at increased risk of contracting or transmitting STDs. In fact, health challenges such as substance use are higher among lesbian and gay young adults than their heterosexual peers.
But as my colleagues and I have noted before, HIV should be understood as one of the many intersecting and mutually reinforcing health challenges gay men face. This includes STDs other than HIV, as well as substance use, mental health challenges and violence. These are all issues health-care providers must and should address if we are to provide young gay men with the best care possible.
This means that health-care providers need to view the health of young gay men within a broader context of personal health and not solely defined by HIV. But this often doesn’t happen.
It also reinforces the importance of culturally competent health care in which these young men can talk openly about their sexuality and health, without being judged, and where providers are fully knowledgeable about the myriad health issues these men face.
Young men aren’t getting the health care they need
I am the principal investigator for the P18 Cohort Study, an investigation of young men who have sex with men, whom we have been tracking since they turned 18. We have found that these young men face a number challenges getting the health care they need.
When we assessed these young men at the onset of the study (ages 18-19), only half of our sample reported a recent sexual health screening, and only 16% reported a rectal screening in their lifetimes, yet all were sexually active. For sexually active men, such screenings should be routine.
More recent data from of our cohort at ages 22-23 reveals equally troubling information. Of the 349 young men assessed thus far, we have found that close to 10% already have been exposed to syphilis, 2% were actively infected with either urethral or rectal chlamydia, and 2% with urethral or rectal gonorrhea. Such data indicate the health burdens young gay men continue to face, and that many are either not accessing care or are not being routinely screened for these infections by their providers.
And in terms of vaccine-preventable disease, less that 10% of these young men report having received the full dosage of HPV vaccination, which in future could protect them from developing rectal and genital warts and certain forms of cancer.
Most alarming is the fact that close to 40% had not accessed any medical care at all in the previous 12 months and some 60% do not have a primary source of health care delivery. Only 20% reported receiving care from a primary care provider in the same time period, despite the fact that most of these young men are insured, with approximately 7% covered via the Affordable Care Act.
Health care for young gay men is often simply defined by prevention and treatment for HIV, despite the myriad other health challenges these young men may face. Comprehensive care includes screening and services for mental health and substance use, cardiovascular health and comprehensive testing for sexually transmitted infections other than HIV. Primary care can also link these young men to state of the art HIV prevention treatments such as PrEP.
Why are these young men having such trouble getting care?
First, men across the age spectrum, regardless of sexual orientation, are less likely than women to access health care.
Second, while a recent study has shown that young adults want and value health insurance, this doesn’t mean that they’re equipped with the tools to navigate our highly complex health-care system.
Third, for young gay men, especially those residing outside large urban centers such as New York or Los Angeles, finding culturally competent care creates yet another hurdle. And while the Affordable Care Act allows young adults to remain covered under their parents’ insurance plans until age 26, this may not be of particular benefit to young gay men who are not out to their parents or who experience homophobia and rejection from their parents. Young gay men who remain on their parents health insurance may be concerned about confidentiality. For this reason advocates have called for privacy protections.
And young men can start to fall through the cracks early – navigating the transition from a pediatrician to a doctor who can look after the needs of an adult can be difficult for this population. As children and adolescents, they might not have been out to their families or to their doctors, and might not have felt comfortable asking for advice about finding a new doctor. Managing the transition from pediatrician to a new doctor is critical. It helps keep these young men engaged with health care and sets them on a trajectory for lifelong health.
Why culturally competent care matters
Whether you are asking your doctor about getting a flu shot, or asking for an STD test, it is critical that you feel comfortable talking with them about all aspects of health. But it is often very difficult for the LGBT population to find culturally competent care. According to a 2011 Institute of Medicine report, this lack of a comprehensive understanding of the health needs of the LGBT population is one of the drivers behind the health disparities this population experiences.
We must ease the delivery of care for young gay men and develop points of entry into the health-care system in environments where young gay men socially navigate, like schools, mobile units near to clubs, bars, parks and recreational facilities, and within LGBT community centers. This would make engagement easier and less intimidating than in a traditional doctor’s office.