LGBTQIA+ health care and the role of inclusive data: in conversation with Dr. Shanna Stryker
Published June 28, 2023
In honor of Pride month, we sat down with Dr. Shanna Stryker (MD, MPH, Assistant Professor of Clinical Family and Community Medicine at the University of Cincinnati) to better understand her work with LGBTQIA+ patients, the structural and social health care barriers they face, the way policy and politics directly affect LGBTQIA+ health, and the role the GBD data could play to inform health disparities across the various determinants, including sexual orientation and gender identity.
While Dr. Stryker was getting her master’s in public health, she discovered a love of data and the way it can tell a story that puts individual experiences into a population-wide context. This storytelling is especially important when trying to move the needle on health disparities for underserved populations like the LGBTQIA+ community that Dr. Stryker serves in Cincinnati. Hiding your true self takes a toll on your health, Dr. Stryker says. Gathering more accurate and inclusive data from LGBTQIA+ individuals is just one idea she has for making a difference on a structural level.
Interviewed by: Maja Pašović, MA, MEd, Research Manager, Co-Chair of DEI Council, and Rainbow Employee Resource Group lead at IHME.
Tell us more about your work and what prompted you to join the GBD Collaborator Network?
I work as a physician, researcher, and medical educator at the University of Cincinnati, a large university in the Midwest United States. I am fellowship-trained in global health and see patients half-time in a local community health center that serves mostly the regional LGBTQIA+ community and people living with or at risk of HIV. About 75% of the patients I see are transgender/gender-diverse adults, and I provide comprehensive primary care for them, including gender-affirming hormones and/or antiretroviral medications for HIV prevention or treatment, when appropriate. I was also trained as a psychiatrist, and so am able to provide psychopharmacology management for many patients, many of whom are survivors of trauma.
Much of my research uses community-based participatory designs, mixed methods, or implementation science approaches to improving the delivery of health services to transgender/gender-diverse populations, and/or immigrant and refugee populations. I also have ongoing work in Guatemala, where my department has a long-lasting partnership with an organization that provides primary care services to rural, indigenous communities. Beyond supervising residents on one of our quarterly trips there, I have also partnered with psychologists from Guatemala City to provide mental health education for their staff.
Lastly, I teach medical students and resident/fellow physicians. I am the program director for our global health fellowship in the Department of Family and Community Medicine at the University of Cincinnati College of Medicine and will be assistant program director for the Sawyer Pardo Fellowship for LGTBQ+ Health that we will be starting in 2024.
I joined the GBD Collaborator Network because I believe in the power of data to help tell stories to people that can influence policy and improve health equity. I frequently use the GBD results to learn about health trends in countries in which I work or my patients come from, and particularly to demonstrate the gap between the need for mental health services and the supply of mental health services. The GBD Collaborator Network has been an exciting way to get more involved in the available data and in the work being done and shared.
We are in the midst of Pride Month, commemorated around the globe for the significant progress and strides realized by the LGBTQIA+ community and its allies in terms of advancing queer rights and contributions to improving the lives, freedom, and safety of queer individuals. Pride Month also serves as a stark reminder that progress on LGBTQIA+ rights is still very much lagging in many parts of the world, and that more work is needed. What does Pride mean for you personally?
As you alluded to, Pride Month involves a lot of mixed feelings for me. Pride should mean being able to authentically represent yourself, and should mean love-positivity and (consensual, respectful) sex-positivity. It should mean freedom and courage. Celebrating queerness is important, and despite the evidence that queer people have existed across the globe and across cultures for centuries, we see queerness being criminalized, suppressed, and erased. Here in the United States, we are dealing with a tidal wave of anti-LGBTQIA+ legislation, and yet many queer people here still have more freedom or access to care than in other parts of the world. So for me, Pride can involve celebration, but importantly also involves protest and advocacy. After all, Pride has origins in protest.
What are the most important lessons you’ve learned from your work with LGBTQIA+ patients and the area of LGBTQIA+ health in general?
Working with LGBTQIA+ patients clearly shows the impact that social and structural determinants of health have on behavior and directly on health. It also shows the importance of community and of (biological or chosen) family. The way that stress and disenfranchisement and rejection drive non-communicable disease and drive behaviors that directly affect health is profound and observable. More than any other group I have served, the health of my LGBTQIA+ immigrant patients is affected by politics, in a terrifying way.
Many of my patients have high levels of medical mistrust due to a history of medical trauma or anticipated rejection/discrimination. Having a safe, trustworthy place to get care where you are welcome to be yourself and be honest about your health behaviors and your struggles can be life-saving, and it is a privilege for clinicians to serve the LGBTQIA+ community.
What are some of the biggest challenges/obstacles you’ve faced in the scientific research on LGBTQIA+ communities?
I think the biggest challenge is in the lack of sexual orientation and gender identity (SOGI) data collection. We have seen that disaggregating data can help show disparities that disproportionately affect women who are cisgender (compared to men who are cisgender), but often we are not collecting the right data to determine sexual orientation or gender identity (for those in whom this is different than the sex designated at birth). Sometimes it is because the researchers were raised (like most of us) in a hetero-centric and cis-centric culture and did not think to include these questions if they do not have a lot of exposure to queer identities, but other times it may not be safe to do so, especially in countries in which data may be used to enforce homophobic/transphobic laws.
What would be your advice to early-career professionals in public health working toward highlighting the inequities and disparities in access to health care for LGBTQIA+ individuals?
Do your homework! Do this even if you are a part of the community, because the community is large and diverse. Never stop being curious and learning. Do not make your clients/patients educate you, because there are plenty of resources to do your own learning through the internet. The LGBTQIA Health Education Center is great, but also read memoirs by LGBTQIA+ folks, and listen with an open heart and mind at public community events. Then, actively partner with LGBTQIA+ folks when you are doing research or designing programs and give them compensation and professional opportunities for their involvement.
As of right now, what are some of the most salient disparities in health that queer individuals and their families are faced with? Where do you see the biggest need to invest resources?
Unfortunately, we see higher rates of most chronic diseases, disability, mental health problems, and even mortality among LGBTQIA+ populations, especially those that are transgender/gender-diverse and/or those with additional minoritized identities. This is driven in large part by social and structural determinants of health, which contribute to stress and inflammation. Previously I had recommended partnering with those with lived experience when doing this work (even if you are a part of the community yourself). Since we see so many disparities, let them tell you where to start!
One of the ways that I choose to invest my limited time and resources is in education, because despite these health disparities, so many LGBTQIA+ people avoid or delay care because they so often receive mistreatment within medical settings or cannot access it. Training the next generation of public health and clinical professionals to open their hearts and minds to caring for this vulnerable group will (hopefully) have a ripple effect that makes a big impact on health outcomes. In addition, investing in better SOGI data collection in places in which it is safe to do so would help to tell the story of these health disparities in a meaningful way. Data can be powerful and can hold people and systems accountable.
What advancements in health data collection should be made to help public health professionals and researchers study the disparities in health for LGBTQIA+ individuals?
When the data would be helpful to show disparities and cannot be linked to individuals or used to enforce criminalization of LGBTQIA+ individuals, there are a few best practices to follow. The US National Institutes of Health Sexual & Gender Minority Research Office released a resource in 2022 that helps with this.
What role do you think health research institutes like IHME could play in advancing the field of LGBTQIA+ health on a global level?
Advocating for the best practices in SOGI data collection would be a great start because it could help show the impact of homophobic/biphobic/transphobic policies on health, which could prompt change. Also, understanding the mechanism for these disparities through different biological, social, or behavioral mechanisms would help inform interventions. We know that the disparities exist, and it is now time to find more ways to intervene on individual, interpersonal, community, and societal levels.
What motivates / inspires you most in your day-to-day work? How would you like for your work to be remembered?
Trans and queer joy! There really is nothing like someone being free to be their authentic selves and show it to the world without worrying about their safety. Constantly worrying about rejection and safety does not leave much room for thriving or love. This world could sorely use more joy and love.
It’s ambitious, but I would love for my work to be an example of how physicians can be accomplices for trans liberation.
If you had a magic wand, what are the three things you would change in the world?
- Gender equity (across genders)
- Racial equity (across skin tones)
- Improved mental health literacy for all
What are the three books you’d recommend to anyone reading this interview?
- Transgender History by Susan Stryker
- Redefining Realness by Janet Mock
- Asylum by Edafe Okporo