Medical profession bias against sexual minorities threatens the health of Iranian sexual minorities during the COVID-19 pandemic

To the Editor

Inequality in access to health care is a significant public health concern. One group at risk of inequality in health care is sexual minority, who have limited access to health care due to social, structural and economic barriers. Some of these structural barriers are the medical authorities and institutions that have historically shown their open hostility towards the sexual minority. The American Psychiatric Association defined homosexuality as a pathological condition until 1973, and by 1987 not accepted the ‘normal variant view of homosexuality’. And it was only in 2013 that all sexual orientation items were removed from the Diagnostic and Statistical Manual of Mental Disorders.

Although attitudes and laws concerning sexual minorities have changed dramatically over the past decade, it has been found that explicit heterosexism has decreased significantly among physicians in recent years; however, research shows that health care providers implicitly or explicitly prefer heterosexuals over lesbians and gay men (Sabin et al., 2015). There is still a growing form of inequality in access to and use of health care, such a way that the sexual minority in health care institutions have been exposed to unequal treatment. And this is doubly the case in some countries where the identity of homosexuality is ignored, especially countries where homosexuality is illegal. Iran is one of the countries with the highest restrictions on sexual minorities. In Iran, sexual minority completely denied and the country’s political authorities generally deny the existence of a sexual minority (Kabir and Brinsworth, 2021), and because of this denial and neglect, very little health-related research has been done on sexual minority. Therefore, health care providers know little about sexual minorities and sometimes look at them in a degrading way, which can lead to discrimination in receiving medical services.

Other dimensions that lead to unfair access to health care include lack of health insurance coverage, not recognizing the same-sex partners in insurance coverage and lack of health care providers trained in sexual minority health care. Accordingly, the World Health Organization (2013) has called for immediate action against discriminatory laws and practices against sexual minorities. Moreover, the COVID-19 pandemic is more felt in groups that have previously been marginalized by systemic discrimination and oppression. Sexual minorities as one of these groups have been disproportionately affected by the economic and social dimensions of COVID-19 compared to heterosexuals. As a result, we state that sexual minorities are more likely to be exposed to COVID-19, because they are more likely to work in underpaid ‘essential industries’ that require face-to-face contact, which results in increased potential to exposure. In addition, if they get COVID-19, they are more prone to health care discrimination, which can put their lives at risk. Therefore, we recommend to all health authorities in countries such as Iran where the sexual minority is ignored or countries that are less sexual minority accepted:

1. Use of trained health care providers who have the least orientation and bias towards the sexual minority, as well as training medical students and medical professionals in recognizing unconscious bias.

2. Create primary care and health care centres for LGBT people. And during COVID-19, in each city or state, a selected hospital should be designated as the sexual minority hospital.

3. Give priority in vaccination during COVID-19 and also reduce treatment costs.

4. De-stigmatize homosexuality by passing anti-discrimination and hate-crime laws.