Few organizations have as great an influence on public health as the American Medical Association (AMA). The group has a long history of working to see that current, evidence-based medicine becomes the standard for physicians as individuals, as well as for public policy. Four years ago, the AMA saw its first LGBTQ representative, Vanderbilt’s Professor Jesse Ehrenfeld, elected to the Board, and this summer Ehrenfeld became the first LGBTQ Chairman of its Board of Trustees.
Shortly after assuming the role, Ehrenfeld and I discussed the role of the Board of the AMA, what it has done and will continue to do in the realms of LGBTQ healthcare, and the progress that has been made in LGBTQ healthcare in Middle Tennessee over the last decade.
Grady: Tell me a little bit about what the board does and what role the chairman has with that.
Ehrenfeld: The governance of the AMA is really pretty extraordinary. It brings together the entire profession: all of the states and specialty societies come together to set policy through their democratic process. There are two policymaking meetings every year, one in June and one in November. And that policy is then executed through the actions of the Association, which is overseen by the Board of Trustees, led by its Chair, who serves as the primary spokesperson for the Board.
Photo courtesy of Vanderbilt University
Grady: As the first openly LGBT man on the board, do you feel your presence has an impact on those discussions when they're being held?
Ehrenfeld: Well, the AMA is deeply committed to helping achieve greater health equity, across healthcare, and that happens in a variety of ways ... by trying to understand at a system level how we can identify and eliminate inequities. And that includes, obviously, the disparities faced by the LGBTQ community. My perspective as an LGBTQ person, in conversations around how do we try to get better, meaningful, affordable healthcare coverage to all communities, I think is important because, unfortunately, LGBTQ people have been invisible, in many conversations, for decades, at the highest levels of our associations in trying to improve health equity.
Grady: In recent years, what have been some of the most prominent efforts that the AMA has been behind or has supported in terms of LGBTQ health and healthcare?
Ehrenfeld: For a long time the AMA has had policies supporting equal rights, opposing discrimination based on sex orientation and gender identity, and that is foundational for the work that the Association has done. The AMA has a long list of policies that informs healthcare systems and patients about how we can best support LGBT people and fight against discrimination and abuse.
Those policies include work that we have done to try to help prevent violence against transgender people … to form better partnerships to educate not only the public, but law enforcement and legislators about hate crimes against transgender individuals.
The AMA has long championed opposing the stigma associated with HIV epidemic, which is very important to our community. We just passed additional policy advocating ending criminalization of HIV status, and trying to continue to have evidence based practices and recommendations driving policy across the country.
There's also a long list of patient-centered policies around trying to inform patients about their rights to receive equal and equitable treatment, and encouraging research into areas of need in the community that we don't really fully understand. For example, encouraging research into the long-term impact of administration of hormone replacement in transgender patients: we just don't have great data on those kinds of issues. At the AMA we are trying to support better understanding of the evidence, and to generate the evidence, for our patients.
And, as you're probably well aware, the AMA believes that all Americans should have access to meaningful, affordable healthcare that is foundational to improving the health of our nation. And we're firmly committed to making sure that LGBTQ people are a part of that. And we remain committed to ensuring that we protect coverage gains that we've had through the Affordable Care Act and continue to expand coverage for those who currently don't have it.
Grady: What role does the AMA play in educating its members about social issues or about the way social issues interact with the delivery of healthcare?
Ehrenfeld: We take a fairly proactive stance. And there are a number of ways that we do that. We obviously have policies that we then make available to our members, physician members, as well as Association members. that participate in trying to improve access. We have a really growing wonderful education center, where physicians and trainees can obtain the latest information pulled from places like the JAMA Education Network online. And we are growing our ability to have more representive LGBTQ content in that education center as a part of our efforts to improve... We are also trying to make sure that LGBTQ people continue to be part of the conversation as we try to improve access across the nation.
Dr. Jesse Ehrenfeld, photo by Susan Urmy (courtesy of Vanderbilt University)
Grady: So starting your tenure as Chairman, what would you like to see accomplished in the coming term, both in terms of LGBTQ health and more generally?
Ehrenfeld: I want to see every American have access to affordable health care. And we're far from that. We've made significant gains with the Affordable Care Act. And we are committed to fixing the current system. I am hopeful that LGBTQ people will be counted, recognized, and brought along with so many other populations that have been marginalized and not recognized as having unique needs for far too long.
Grady: In the public imagination, what are some of the least thought about health issues that LGBT people face?
I think there's a lot of focus on things that are different for LGBTQ people—vaccinations, PrEP, some of those kinds of things that are a little bit different in terms of recommended guidelines. But I see a lot of need, and it's not talked about unfortunately, in the behavioral health space. So many LGBTQ people suffer from stress and behavioral health challenges of being an LGBTQ person, particularly in the South, where there is data showing that additional stigma becomes an additional burden. We know that that continues to be a challenge for people and is not often discussed, I think, as widely as some medical issues related to LGBTQ health.
Grady: You’ve been in Nashville for nine years now, and you are headed to Wisconsin in September. In your decade in Nashville, given your work in LGBTQ health at Vanderbilt, what are you proud of that has been accomplished during your tenure?
Ehrenfeld: I am extraordinarily proud of the huge gains that I've seen across the region in terms of access to highly competent care for LGBTQ people. And it's not that we haven't had wonderful facilities and physicians and providers providing care across Middle Tennessee, for LGBTQ people, for a long time that predates my arrival. But with the development of the LGBTQ program at Vanderbilt, I think there is now a much better, organized, systematic way of patients getting connected to the care that they need. And I'm incredibly proud of that.
The fact that we have now four transgender clinics at Vanderbilt that didn't exist three years ago is an extraordinary step forward to provide access to care. The fact that we have clinics and specialists to have deep knowledge and expertise to provide care is just extraordinary. But there are still huge unmet needs. And I still get calls every week from patients who struggle to access care because of either non-insurance or under-insurance. And those are systematic issues that we really need to take a look at, across our country, as well as the state level. But I'm incredibly proud of the gains that we've made in Nashville and across the region.
Grady: I know that especially transgender healthcare has come such a long way in Middle Tennessee. Those clinics that have opened, what populations do they serve?
Ehrenfeld: There is a plastic surgery clinic for trans patients, there is a pediatric clinic, an adult clinic, and a clinic in women's health. The faculty and the teams are doing a great job of coordinating care. They have been doing a wonderful job of working with partners across the nation in making sure that our practices across the region are in line with standard and best practices informed by the latest evidence base. And I think that the overall experience that patients are having, not just at Vanderbilt but at facilities across the region, has just been greatly improved, because there is a better recognition of what is appropriate, what is needed, and the unique needs of people in the LGBTQ community.
Grady: Both in Nashville and nationwide, with the increased availability of care, have you noticed that there've been more people looking for services, that the need is much larger than was perhaps originally predicted?
Ehrenfeld: Yeah, you know, as the saying goes, "If you build it, they will come." And we have seen at Vanderbilt, and other clinics that we are in touch with across the nation, exponential growth in the number of patients coming in for care and for services. The clinic that we started down in Bellevue was one half-day a week. Within the first year, that was increased to a full day a week, doubling the capacity, simply because the demand far outstripped what we expected to see. And a couple of wonderful things are happening, James: more patients are able to get access to care because of gains in coverage. And there's also now a recognition that the care that we are providing is appropriate, safe, effective, legitimate, and no longer having to be hidden in ways that was happening even as recent as a decade ago.
Grady: What do you think are some of the growth opportunities that Nashville has, building on these gains to meet tomorrow's needs?
Ehrenfeld: Well, we still need to get coverage for everybody. And unfortunately, we're far from that. Millions of people across the country and thousands in Tennessee just don't have health insurance. And we need solutions to make coverage more affordable, because we know that people who don't have health insurance, live sicker and die younger. And we just unfortunately won't solve that problem until we get coverage for everyone.