Bioethics for Breakfast: Social Determinants of Elders’ Health

Bioethics for Breakfast: Seminars in Medicine, Law and Society

Anne K. Hughes, PhD, MSW, and Dawn Opel, JD, PhD, presented at the December 2 Bioethics for Breakfast session, offering perspectives and insight on the topic “Social Determinants of Elders’ Health.” Bioethics for Breakfast is generously sponsored by Hall, Render, Killian, Heath & Lyman. This session was the first of a two-part series on the theme “Paradoxes of Aging: Living Longer and Feeling Worse.” The presentation portion of the session was recorded and is available to watch on our website.

Elders in the U.S. contend with chronic illness, disability, mental health disorders, and a host of other co-morbid conditions. The COVID-19 pandemic has illuminated the complex web of social, medical, and economic challenges faced by the elderly.

Anne K. Hughes, PhD, MSW, highlighted common concerns about aging and explained how those concerns affect LGBTQ+ older adults: cognitive and/or physical decline, isolation, financial/legal, living situations, and meaning making/legacy. Hughes shared the importance of health professionals asking questions rather than making assumptions when working with sexual and gender minority older adults. She also noted research showing health disparities at greater levels when compared to heterosexual older adults, even noting that much of the research data currently available is not inclusive of bisexual, transgender, or gender non-conforming older adults.

Dawn Opel, JD, PhD, presented on older adults and food insecurity in America. She addressed the invisibility of older adults experiencing hunger in America, lessons from the COVID-19 pandemic, programs and services available for older adults in Michigan, and the future of food security for older adults. Regarding food insecurity, many older adults are living alone, and they may use trade-offs such as skipping their grocery trip to instead pay the rent or utility bill. The pandemic also made visible the reliance on unpaid caregiving and volunteerism for access to food. Sharing data that projects more than 20 percent of the U.S. population will be over the age of 65 by 2030, Opel asked attendees to consider the actions needed now to invest in infrastructure for the future.

Discussion during the Q&A portion included the concept of aging in place, with multiple attendees sharing personal anecdotes about older adults in their lives who wish to remain independent in their homes. Broadly, both speakers touched on the importance of having conversations early on with older adults in our lives, in order to be as prepared as possible before there is a crisis situation. Discussion also touched on the technological divide, having conversations with primary care physicians, and potential policy improvements that could improve the burden on those in paid and unpaid caregiving roles.

About the speakers

Anne K. Hughes, PhD, MSW, is Director and Associate Professor in the School of Social Work at Michigan State University. She was previously the director of the PhD program. She is co-founder of the MSU Consortium for Sexual and Gender Minority Health Across the Lifespan, an interdisciplinary research consortium established within the College of Social Science in 2019. Prior to coming to MSU Dr. Hughes had 14 years of clinical practice experience. Dr. Hughes’ research focuses primarily on older adults with chronic conditions and improving healthcare services for underserved older adults, particularly LGBTQ+ older adults. Dr. Hughes has received external funding for her research from: Patient-Centered Outcomes Research Institute (PCORI), the John A. Hartford Foundation, and the National Institutes of Health. She is a Hartford Faculty Scholar in Geriatric Social Work and a Fellow in the Gerontological Society of America.

Dawn Opel, JD, PhD, is Director of Research & Strategic Initiatives and General Counsel of the Food Bank Council of Michigan, where she oversees research, data, legal, and compliance functions of the organization. A lawyer and researcher, her career has included positions in academic, nonprofit, and government sectors, and broadly, she works to build strategic partnerships for social innovation. Dr. Opel’s particular focus is developing capacity in Michigan for food-as-medicine interventions in the clinical setting, and she is currently involved in the implementation and sustainability of fresh food pharmacies for chronic disease self-management in federally-qualified health centers (FQHCs). She holds a PhD from Arizona State University and a JD from the University of North Carolina School of Law. Dr. Opel is adjunct assistant faculty at Michigan State University in the College of Arts & Letters.

What do LGBTQ patients want from their healthcare providers?

Bioethics Public Seminar Series purple and teal icon

The 2020-2021 Bioethics Public Seminar Series continues later this month with a panel of MSU alumni. You are invited to join us virtually – events will not take place in person. Our seminars are free to attend and open to all individuals.

Controversies and Complexities in LGBTQ Health Care

Event Flyer
Zoom registration:

Do you feel prepared to provide excellent care to your LGBTQ patients? Calls for social justice and corrective actions are being mounted by various and intersectional constituencies. These calls for social change must be reflected in improved clinical care, as well. What do LGBTQ patients want from their healthcare providers? Health professionals often think that they do not serve LGBTQ+ people, but Williams Institute data reports about 3-10% of the U.S. population of adults, depending on state, identify as a sexual and gender minority person. What are some of the ethical and clinical challenges that clinicians and patients face? This seminar will address these broadly understood health issues that impact the LGBTQ community, as we aim toward an inclusive and equitable health delivery system. Bring your questions and take part in this exciting and timely conversation with a panel of MSU alumni.

Jan 27 calendar icon

Join us for this online lecture on Wednesday, January 27, 2021 from noon until 1 pm ET.

Photo of Emily Antoon-Walsh
Dr. Emily Antoon-Walsh

Emily Antoon-Walsh, MD, MA, FAAP (she/her), is a board-certified pediatrician who specializes in the care of hospitalized infants, children and adolescents. She graduated from the Michigan State University College of Human Medicine in 2013 with an MD and an MA from the Bioethics, Humanities and Society program. She completed her pediatric residency at Seattle Children’s Hospital/University of Washington. As a medical student she worked to improve medical education around LGBTQ issues. As a resident she interviewed trans youth and their parents about barriers to gender-affirming care. She now practices hospital pediatric medicine, which presents special challenges and also privileges in providing LGBTQ-affirming care for families. She works in a community hospital in Olympia, WA, where she lives with her wife and child who is a true Pacific Northwest baby and loves the outdoors on the rainiest, cloudiest of days.

Photo of Barry DeCoster
Dr. Barry DeCoster

Barry DeCoster, PhD (he/him), is an Associate Professor of Bioethics and Philosophy at Albany College of Pharmacy and Health Sciences. His research interests focus on the overlapping areas of bioethics and philosophy of science & medicine. DeCoster is interested in how vulnerable patients—such as LGBTQ health, racial minority health, and women’s health—engage and respond to the particular needs of their communities. He is also interested in the lingering impact of the medicalization of LGBTQ health and how queer patients are themselves constructed as both ethical and epistemic agents. Dr. DeCoster received his B.S. in Biotechnology & Humanities from Worcester Polytechnic Institute, and his M.A. and Ph.D. in Philosophy from Michigan State University. He spent much time working at MSU’s Center for Ethics as a grad student, and remembers that time fondly as a source of mentorship. Dr. DeCoster enjoyed the opportunity to teach fantastic students for three years at MSU’s Lyman Briggs College.

Photo of Henry Ng
Dr. Henry Ng

Henry Ng, MD, MPH, FAAP, FACP (he/they), is a physician, educator and advocate for LGBTQ health. Dr. Ng has been involved in LGBTQ health care since 2007 and he is currently a physician in the Center for LGBTQ+ Health and the Transgender Surgery and Medicine Program at the Cleveland Clinic Foundation. He completed his BS and his MD at Michigan State University. He completed his residency and chief residency in Internal Medicine/Pediatrics at MetroHealth Medical Center. In 2012, he completed a Master’s in Public Health degree at Case Western Reserve University with an emphasis on Health Promotion/Disease Prevention for LGBT populations. He served as an associate editor for the journal LGBT Health and is a senior associate editor for the journal Annals of LGBTQ Public and Population Health.

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

Cis, Trans, Gay, Straight: Being Called Out by the Doctor

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Jamie Lindemann Nelson, PhD

A little story—it might be called a dramatization—to start: Approaching the third trimester of pregnancy number two, Maria is in for a routine exam. Everything goes as expected until her OB/GYN pauses, gathers herself, and asks, “By the way, Maria … and don’t feel that you have to answer if you don’t want to, but … you do think of yourself as a woman, don’t you … I mean, you … identify as a female gendered person … who … is mainly attracted to men, erotically?”

To say Maria is taken aback by these questions is to say too little; a word like “stunned” comes closer. How to make any sense of this? Has her doctor, who actually attended the birth of her child, had a psychotic break? Is she just trying to be funny? Did Maria just mishear? Or is this some politically correct silliness … does it having something to do with queer people?

Indeed so. The New York Times for this past May 29th reports that LGBT patients are generally willing to disclose their “gender identity and sexual orientation” to their health care providers. Based on research reported in JAMA Internal Medicine, only 10% of a national, randomized sample of lesbian, bisexual, gay, and straight subjects indicated that they would refuse to acknowledge their status; a related study of 101 transgender patients indicated that 90% believed that it was important for primary care providers to know their gender identity.

They are quite right: knowing whether or not a patient is transgender, whether or not they are straight, can sharpen a care provider’s focus. Further, LGBT health care disparities can be spotted and remediated more effectively. Both the National Academy of Sciences and the Joint Commission have endorsed soliciting such information.

Yet, if these results are accurate, LGBT folks should be congratulated not only on their appreciation of quality and equity of care, but also on their bravery. The National Center for Transgender Equality’s 2011 study of 6500 transpeople indicated that 19% were denied access to health care, 28% reported being harassed and disrespected by care providers, and 2% had actually experienced physical assault while seeking care.

Similar perils face LGB patients. A 2010 Lambda Legal study of nearly 5000 respondents roughly anticipated the National Center for Transgender Equality’s results for transpeople, and showed that matters are at least as dire for people with HIV. LGB people who are neither transgender nor living with HIV should not be sanguine—8% report being denied care because of being thought to be otherwise than straight.

This “Transgender-Affirming Hospital Policies” document is available for download on the Human Rights Campaign website.

Perhaps these data no longer accurately reflect the reception of queer and HIV infected people by health care professionals. Yet there’s still reason for them to be wary—for example, a 2017 Human Rights Campaign Foundation report showing that only 61% of 901 hospitals had nondiscrimination policies that included both gender identity and sexual orientation. The Times piece mentioned “several studies” that say “providers feel uneasy about asking,” out of a reluctance “to make patients uncomfortable.” One hopes that their delicacy is informed by awareness of what LGBT folks might be uncomfortable about—as well as by these recent studies.

But if the studies draw a veil over LGBT fortitude, they also seem insensitive to how “do ask/do tell” policies could leave some cisgender or straight patients feeling deranged. Serious efforts to gather this information will mean that people generally will need to be asked about their sexual preferences and about which (if either) gender they happen to be. Should this become routine, that means that, at least in this particular health care context, queer identities aren’t simply being accommodated: they are being made normative.

We needn’t imagine this inquiry going on just as it did with Maria; her OB-GYN could stand a spot of training. The privacy of these disclosures matters too—it isn’t merely in health care settings that LGBT folks have reason to worry about their safety. Still, however conducted, however safeguarded, routine inquiry destabilizes abiding sources of certainty; neither the fact that Maria’s husband was present as she labored, nor even the fact of her laboring, ground the knowledge of identity a provider needs. Like those who have been relegated to the margins of sex and gender, Maria and all other cisgendered, straight patients will need to abide the question, even if asked discretely, even if they choose not to answer it.

The journalist and historian Elinor Burkett has claimed that unlike progressive movements championing African-Americans, those supporting transgender people have not been content to struggle against violence and discrimination. They have also demanded that women “reconceptualize themselves”—most glaringly by questioning whether having a vagina is necessary for being female. While women born with vaginal agenesis would likely have something to say to her, like Burkett, like Maria, many people will be unsettled by calling old certainties into doubt. But socially advantaged people who oppose injustice cannot simply assume that their world will maintain its proportions and just grow to accommodate those hitherto left out. Those who were excluded will have something to say about the arrangements.

Nor is reconceptualization confined to queer activism. When women’s suffrage was an open question, some women worried that wielding political power would change who women were, how they were thought of, and how they thought of themselves. They were right—and for that, we should all be thankful. Telling your health care provider whether you are cis-, trans-, or non-binary, whether gay, or bi, or straight, may seem a tiny matter in comparison, whose health care benefits may seem not worth the time, trouble, and upset they occasion. Yet in putting the powerful imprimatur of medicine behind the need to respect some of the deepest sources of human self-understanding, the time, the trouble, and the upset might be the most important result of the whole process.

Jamie Nelson photoJamie Lindemann Nelson is a Professor in the Department of Philosophy at Michigan State University. Dr. Nelson is a co-editor of IJFAB: International Journal of Feminist Approaches to Bioethics.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, July 6, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Nelson: Bathrooms, Binaries, and Bioethics

Click through to view references

Bathrooms, Binaries, and Bioethics

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. Visit this page for more information.

By Jamie Lindemann Nelson, PhD

Bioethicists typically deal with the moral complexities that emerge when social institutions—the clinic and the lab, chiefly—try to fend off our bodily vulnerabilities or ease their physical and social consequences. Recently, however, major social institutions have acted to make some people’s bodily vulnerabilities harder to deal with, hampering their access to means of coping with them that otherwise are publicly available.

The vulnerability I refer to is the regular need to eliminate the waste our bodies generate; “some people” are transgender women and men, boys and girls; the culprits are a wide selection of American state legislatures. Spring 2016 may go down in the annals of infamy as the season when lawmaking bodies across the country became fixated on the subject of bathrooms. The South Dakota House of Representatives narrowly sustained the governor’s veto of a measure passed by large majorities in both legislative houses that would have forbidden transgender students to use bathrooms, locker rooms, and showers designated for use by members of the gender with which they identify. In Tennessee, a bill that extends the bathroom ban to public universities as well as middle and high schools unanimously passed out of committee. Briefly stalled due to public hearings at which transgender high school students eloquently testified, the bill was quickly revived and sent on, only to stall again; its future remains uncertain. Unwilling, perhaps, to encounter eloquent North Carolinian trans students, the legislature there called a special session to ram through a sweeping bill that undercut the ability of local governments to extend anti-discrimination protections to LGBTQ folks generally; this haste was prompted, apparently, by the specter of trans people being expressly welcome to gender-concordant loos in Charlotte. Unimpeded by vetoing governors or eloquent students, this measure is currently the law in North Carolina. Nor is this all. According to the Human Rights Campaign, 44 anti-trans measures are under consideration in 16 states.

The typical rationale for barring trans people from their lavatories is to protect privacy and safety. To speak gently, this is ill-considered: there is no reason to regard a transwoman as a particular threat to any other woman occupying the next stall. No cisgender man standing at a urinal has any special cause to fear the transman washing his hands at the sink. Any heightened danger of being menaced would run in the other direction: a transwoman forced to use accommodations designated for men might well have good reason to be concerned about her safety. Privacy is a more amorphous notion, but however it is meant, it seems unlikely to be furthered by forcing transmen to enter women’s lavatories, or forcing transwomen to use the gent’s.

Bioethicists, who generally favor clarity about risks and benefits as they concern bodies, should be among those pointing this out. They might also help spread the word that enforcing such measures heightens risks of pain, distress, and ill health to those who, during the course of a long work shift or school day, can’t bring themselves to use discordant facilities, or fear making themselves conspicuous by using whatever alternatives might be present. There is also disturbing evidence that barring trans people from facilities matching their gender identification contributes to their strikingly elevated suicide rates (Seelman).

But the matter doesn’t end with getting clear about who is more at risk than whom—if that were really at issue, none of these bills would have taken up any legislature’s time and money. What then is behind these efforts to crimp transpeople’s access to concordant lavatories, and thus to hamper their access to much of social life generally? A clue was provided by South Dakota state representative Stephen Haugaard. In a bravura performance of metaphoric derangement, Representative Haugaard called transgender a “virus that has broken out” across the nation, while also asserting that being transgender is a matter of decision. “When you feed the fire of this kind of confusion,” Haugaard said, “you’re going to add to the number of people who are going to make this choice.”

Not that these bills—which frequently stipulate that sex is determined by anatomy at birth, by chromosomes, or in accord with original birth certificates—need such dicta to reveal their intent; they do a pretty good job speaking for themselves. The language that blocks recognition of any kind of gender crossing makes it clear that the real target isn’t preserving anyone’s safety or privacy. The drive is to use the law, not only to limit trans presence in public spaces, but to fight the uptake and circulation of how transpeople understand themselves—in short, to delegitimize transgender people as such.

Anti-transgender laws are part of a general reactionary effort to hold certain people in the subordinate or frankly abject positions in which social traditions have assigned them—forced to give way on same-sex marriage, the imagined immutability of the gender binary is the new line in the sand. As bioethicists have noted, medical practices that engage trans people have played both sides of that line—both pathologizing and affirming the distinctive ways in which transgender constitutes an invitation to respond more richly to reality’s complexities. A challenge now for bioethics is to nurture the affirmative side of this legacy, helping to clarify for medical personnel and the public how what has been fancied a natural binary in fact is maintained by intricate expressions of social power. If bathroom access is where those who still root for reaction draw today’s line, let’s be sure that it is drawn in beach sand, and welcome the incoming tide.

jamie-nelsonJamie Lindemann Nelson, PhD, is a Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 5, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

Click through to view references