How is Health Care Underserving LGBTQ+ Iowans?

Eliminating health and health care disparities has long been a focus in the field of public health. While differences in health outcomes by age, sex, race, ethnicity, education, geography and socioeconomic status are arguably well-documented, there remains a dearth of information on disparities among sexual minorities. A DMU faculty member is among those who are working to fill this critical gap.

Elizabeth Baker, Ph.D., M.P.H., CPH, assistant professor of public health, was invited to be a co-investigator on a study led by Paul Gilbert, Ph.D., assistant professor in the community and behavioral health department in the College of Public Health at the University of Iowa. The study’s main objective is to gather descriptive data on the health status and needs of lesbian, gay, bisexual, transgender, queer and other sexual minorities (LGBTQ+) in Iowa to inform future health initiatives and serve as a baseline to better identify trends and disparities in health and health care.

Partners in the study include One Iowa, the state’s largest LGBTQ+ rights advocacy group, and the Iowa Cancer Consortium.


“Experts are calling for more representative health-related surveys that collect information from sexual minorities, stressing that epidemiologic profiles are necessary to monitor health trends, plan health promotion activities, and develop and reinforce just legislation for our LGBTQ+ citizens,” Baker says.


Dr. Elizabeth Baker is fulfilling the oath she took as a public health professional in part as a co-investigator on a study that’s examining disparities among a “sub-population of disenfranchised Americans.”

Such efforts are exemplified by Healthy People 2020, a set of objectives for health promotion and disease prevention issued by the U.S. Department of Health and Human Services (HHS). It includes a goal to “improve the health, safety, and well-being of lesbian, gay, bisexual and transgender individuals.”

However, current policymakers are undermining these efforts, say Baker and numerous other health professionals. For example, in March 2017, Tom Price, then U.S. HHS secretary, announced that demographic questions regarding gender identity and sexual orientation would be eliminated from the National Survey of Older Americans Act, a survey of seniors who receive social support and nutrition programs funded under the Older Americans Act.

“This is problematic, because existing studies report that LGBTQ+ seniors face acute levels of economic insecurity, social isolation and discrimination,” Baker explains. “With this new directive, no data on LGBTQ+ seniors will be available for the next several years, at minimum, that would help ensure HHS programs are meeting the needs of this vulnerable population.”

Likewise, HHS announced that similar demographic questions would be excluded from the upcoming 2020 U.S. census, a survey conducted every 10 years to gather data on everything from the number of persons in a household to household plumbing facilities. In response, federal agencies and numerous Democratic leaders spoke against the decision, noting that this data would provide informational support to enforce existing laws and ensure appropriate legislation to improve the lives of the LGBTQ+ community at large. However, it will now be 12 years – 2030 at the earliest – that stakeholders may have a pulse on health issues faced by the LGBTQ+ community.

Similar demographic questions were removed in 2017 from the Centers for Independent Living Annual Program Performance Report, which guides HHS in evaluating programs that serve persons with disabilities and ensure they can live independently in their homes and communities.

“This is, again, concerning, because available research suggests that LGBTQ+ citizens face significant barriers to accessing services,” Baker says. “Consequently, the responsibility of data collection and dissemination has fallen on other stakeholders that aim to raise awareness of and address disparities in the LGBTQ+ community.”

Phase I of the study Baker is participating in, an online survey from June to December 2017, is complete. Preliminary analyses of data collected from more than 500 LGBTQ+ Iowans suggest these citizens experience an alarming rate of violence, with 50 percent reporting sexual abuse in their lifetime and only 37 percent reporting no lifetime experiences of discrimination in public. Likewise, while most participants report high levels of civil engagement, few feel safe “all of the time” (17 percent).

Are you looking for a safe space to join one of these difficult conversations?

Elizabeth Baker points to programs offered by DMU’s Office of Multicultural Affairs that “necessarily challenge students, faculty and staff to examine their own cultural biases and stereotypes so that they can practice cultural humility and deliver highly competent, compassionate care.” These programs include Safe Zone training, which fosters LGBTQ+ allies, and the Diversity Health Series, which examines the impact of culture on health and health care outcomes.

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Simultaneously, for Phase II, Baker is moderating a series of focus groups with community members to enhance the team’s understanding and interpretation of their quantitative findings. One finding that has important implications for health care providers is that, in general, participants report non-disclosure of their sexual or gender identity to providers. The main reasons for this seem to be a desire to avoid the frustrations of “dealing with” untrained health providers and a fear of discrimination.

Already, the study has garnered much attention. In November 2017, Gilbert was invited to share the team’s activities on Iowa Public Radio. In February 2018, Baker was a guest speaker at the sixth annual LG - BTQ+ Health and Wellness Conference, hosted at DMU. The collaborators also debuted their initial findings at the 2018 Governor’s Conference on Public Health in April and aim to present a more complete analysis at the American Public Health Association’s annual meeting in 2019. Baker is mentoring several DMU osteopathic medical students and an Iowa State University undergraduate who are assisting with Phase II of the study and supported the submission of an NIH grant to extend the study to LGBTQ+ adolescents in Iowa.

“Obviously, this is a politically charged subject. Concrete actions have been taken that LGBTQ+ advocates argue risk ‘erasing’ the experiences – i.e., data – of an entire sub-population of disenfranchised Americans,” Baker says. “However, the oath I have taken as a public health professional calls me to address fundamental causes of disease, advocate for and empower the disenfranchised, and seek information needed to implement effective policies and programs that protect and promote health for all. As such, I stand as a strong ally of the LGBTQ+ community, and I am honored to be part of this work that exemplifies public health research and practice.

“I reflect daily on how we teach this in the context of an unjust society,” she adds. “To promote positive patient-provider interactions, we must acknowledge and navigate the reality that we are practicing in a culture where harm is pre-existing, especially among the LGBTQ+ community. We must engage in uncomfortable conversations to enhance our practice and provide the best care for our patients and our community.”

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