Oral Health and LGBTQIA+ Populations: End the Stigma, Improve Care

In health care settings, lesbian, gay, bisexual, transgender, intersex, and queer (LGBTQIA+) populations often face discrimination, leading to reduced use of health-related services. While we use the term LGBTQIA+, we recognize that these populations are diverse yet are likely to face structural barriers when accessing health care, similar to other marginalized groups. Despite oral care being crucial to overall health, the oral health status of LGBTQIA+ communities is not often discussed or at the forefront of policy conversations. This June, in honor of Pride Month and National Oral Health Month, we raise awareness about the unique oral health challenges experienced by the LGBTQIA+ community, describe innovative programs, including those within Federally Qualified Health Centers (FQHCs), and provide recommendations on how health care providers can offer inclusive and equitable oral care.

Problem

Oral health is important and associated with overall health and well-being, yet LGBTQIA+ individuals are less likely to access oral care, often citing fear of discrimination and a lack of provider sensitivity. According to recent Census data, roughly 20 million adults in the United States identify as lesbian, gay, bisexual, or transgender. Yet, according to recent research, 31% of LGBTQIA+ individuals state their most recent dental visit took place two or more years ago, with 77% of LGBTQIA+ individuals more likely than non-LGBTQIA+ individuals to report visiting an ER for dental care in the last year.

Providing equitable, culturally sensitive, and affirming care is crucial, considering that 50% of LGBTQIA+ individuals report feeling self-conscious or embarrassed because of their teeth, mouth, or dentures. Discrimination and mistreatment remain barriers to accessing oral care, with LGBTQIA+ individuals reporting judgment and uncomfortable reactions from dental care providers. In particular, transgender and nonbinary individuals reported being refused health care or experience physical and sexual harassment or violence in health care settings 

Inclusivity Recommendations

Training. There are several ways to make oral health practices more welcoming to LGBTQIA+ populations. First, regularly train all team members, including front desk staff, on the stigma and discrimination these populations face and how to provide culturally sensitive, gender-affirming care. Several organizations offer anti-discrimination training for health care professionals, and the CareQuest Institute for Oral Health offers webinars such as Becoming an Ally: Creating an Inclusive Environment for LGBTQ+ Patients. Additionally, the University of Pennsylvania’s LGBTQ+ Community and Oral Health platform is a collection of webinars, best practices, and white papers with the goal of enabling oral health care providers to better serve LGBTQIA+ populations.

Front desk staff are the first point of contact for those seeking oral care and can make or break a person’s experience, and too often these experiences are negative. Recently, members of our Understanding Barriers to Oral Care for People Living with HIV/AIDS (PLWHA) Taskforce cited negative interactions with front desk staff, including discrimination and stigma people living with HIV/AIDS (PLWHA) experience, as a barrier to care. Although these results centered around PLWHA, the experiences shared are applicable across vulnerable and marginalized communities, including those identifying as LGBTQIA+. Front desk staff that are culturally competent and informed on LGBTQIA+ concerns and experiences can help alleviate the stress and fears patients may feel when seeing a dentist. In addition, for many LGBTQIA+ individuals, securing oral care includes its own share of barriers, including being less likely to have health insurance than non-LGBTQIA+ populations. Implicit bias and other sensitivity training for front desk staff is essential in providing the best support and can help fill gaps exacerbated by lower insurance rates and other barriers.  

Gender-neutral bathrooms. Advocacy groups like the Gay and Lesbian Medical Association (GLMA) encourage the use of gender-neutral restrooms to make health care settings more inclusive. This benefits not only patients but employees who may be more comfortable using an all-gender restroom. Organizations like the National Center for Transgender Equality offer broad guidance while the Occupational Safety and Health Administration offers detailed state and local policies on providing all-gender restroom access.

Ask for and correctly use pronouns and preferred names. Organizations like GLMA recommend the use of updated intake forms that collect data on more than just “sex,” and include sexual orientation and gender identity (SOGI) data. These intake forms should follow research-proven examples such as the National Academies’ Examples of Two-Step Gender Measures in National and International Surveys and record preferred pronouns and names, without limiting options to the traditional “she/he.” Accordingly, electronic dental records or other patient information should include these data, allowing practices to better understand their patient populations, inform clinical workflows, and refer patients to appropriate resources when necessary. The Fenway Institute’s Do Ask, Do Tell: A Toolkit for Collecting Sexual Orientation and Gender Identity Data in Clinical Settings includes best practices for collecting and integrating data to improve care delivery, and is relevant to oral health or other types of providers. 

Be a proactive ally. Patients and providers have long-acknowledged the utility of searchable LGBTQIA+-friendly medical practice directories, like GLMA’s LGBTQ+ Healthcare Directory. These directories enable those identifying as LGBTQIA+ to find discrimination-free care and often include resources that enable providers to better serve LGBTQIA+ communities. However, providers need to join these directories in order for them to be effective, and oral health representation is lacking. For example, while the LGBTQIA+ Healthcare Directory is open to dentists, there are only 42 current dental listings compared to 417 family physicians and 305 psychotherapists.

Innovations and Resources

Meanwhile, FQHCs and other safety net settings are working to improve care for LGBTQIA+ populations and close gaps in oral health outcomes. The mission of the Center for Key Populations (CKP) at Community Health Center, Inc., a large health center network in Connecticut, is to provide primary care and social services to populations that have traditionally experienced the barriers to care that lead to health disparities. They offer a wealth of health services and resources to the LGBTQIA+ community, serving as a model of how all FQHCs can help close service gaps while providing care in an LGBTQIA+-affirmative, inclusive, and respectful environment.

Other organizations are also integral in making progress. The American Institute of Dental Public Health (AIDPH) has spearheaded recent work in highlighting the barriers and concerns LGBTQIA+ individuals experience in oral care, including producing a series of webinars that focus on oral care for the transgender community, achieving dental health equity, and strengthening LGBTQIA+ inclusion in dental education. In another example, the CareQuest Institute for Oral Health published “Oral Health and the LGBTQ+ Community: A Snapshot of Disparities and Discrimination,” providing research findings specific to care disparities.

Looking Ahead

For dentists and hygienists, awareness of stigma, barriers to care, care avoidance, and other LGBTQIA+ issues should start during their education. Unfortunately, the few institutions that do include LGBTQIA+-specific content for aspiring dentists and hygienists only spend 3.68 and 1.25 hours total, respectively, on these issues. Research shows that students want more LGBTQIA+-relevant content and feel woefully unprepared to treat patients identifying as LGBTQIA+. Experts recommend adding LGBTQIA+ competency training early in the dental curricula to decrease bias and improve care and advocates. Penn Dental Medicine, NYU Dentistry, and others are at the forefront of incorporating LGBTQIA+ competencies into standard dental curricula.

Broadening pathways to dental education can create a more diverse workforce, increasing workforce opportunities for people of all races, ethnicities, genders, and sexual orientations. Dental practices that include people identifying as LGBTQIA+ as providers and/or staff can help reduce stigma and make patients feel more comfortable discussing important health issues. Incorporating dental therapists, highly-trained providers of preventive and restorative dental care working under the supervision of a dentist, can greatly increase practice diversity while addressing oral health workforce shortages. Currently, dental therapists are authorized to practice in 14 states, though only 10 of these authorize dental therapists to work outside tribal dental settings.

We must acknowledge that accessing dental care is challenging for the general population, but even more so for vulnerable and historically marginalized communities including people identifying as LGBTQIA+. While research demonstrates these barriers are real, gaps remain. More work on how identities intersect to create additional barriers to care, opportunities to improve care, and policy innovations can help increase oral health equity for LGBTQIA+ communities and improve oral and overall health outcomes for communities.