Luis Ojeda dreads going to the doctor.
He is undocumented, and health care can be expensive without insurance. Plus he identifies as queer, so he often feels uncomfortable not knowing how doctors in the conservative-leaning central San Joaquin Valley will treat him based on his sexual orientation.
Ojeda, 27, exists at the intersection of two marginalized communities – those who lack legal status and those who are LGBT (lesbian, gay, bisexual and transgender). Each community has its own set of barriers to health care. Together, those barriers are compounded.
For Ojeda, that means avoiding the doctor unless it’s absolutely necessary. It also means being intentional about where he seeks care. For example, he visits known LGBT-friendly clinics for STD and HIV testing. But if he needs a physical, he goes to low-cost clinics that accept patients regardless of legal status.
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“You decide which part you’re going to present as, depending on what you’re going for,” he said.
In essence, for health care purposes, Ojeda is always either undocumented or queer – never both.
There are at least 267,000 LGBT adults who are undocumented immigrants throughout the country, according to the Williams Institute, a think tank at the UCLA School of Law that specializes in sexual orientation and gender identity law and policy. About 70 percent are Latino and nearly half are under age 30. The actual number could be higher, given that the undocumented population is difficult to estimate and some people are reluctant to disclose their gender identity and sexual orientation.
The Valley’s fraction of that likely is small. Even so, there is a growing effort here to shed light on the so-called “undocuqueer” population and educate health care providers about the needs of undocumented and LGBT residents. Advocates hope to improve the health of people from each community as well as of those who identify with both.
Equality California, the statewide LGBT civil rights organization, launched a two-year effort in 2015 to train San Joaquin Valley health care providers about how to approach LGBT patients and bring visibility to the unique needs of those who also are undocumented.
Rick Zbur, executive director of Equality California, said the project represents a change from the organization’s previous mission. California law has long provided many civil rights protections for LGBT residents. After the U.S. Supreme Court’s 2015 ruling on same-sex marriage, he said, work shifted to addressing the ways in which various forms of oppression – such as racism, sexism and homophobia – are connected.
Zbur said one thing that keeps both undocumented and LGBT people from seeking help is fear of insensitivity. Like Ojeda’s sense of dread, many people worry they won’t be approached by doctors in a way that is culturally appropriate, Zbur said.
Some Valley leaders started converging the immigrant and LGBT movements a few years ago to advocate around health and other issues.
Ojeda, a longtime Fresno activist, has worked with groups including the California Immigrant Youth Justice Alliance and FAMILIA: Trans Queer Liberation Movement, which was founded in 2014 by LGBT immigrants. He also was part of a local undocuqueer talking circle, which shifted to a more general gathering of LGBT people of color.
“That’s becoming a little more prevalent, where we’re mixing the two or we’re able to be more authentic about both identities,” he said. “But it depends on the situation.”
Equality California found Valley doctors are more likely to know how to communicate with immigrants than those who are LGBT. That means using words like undocumented instead of illegal and not including a line for a Social Security number on intake forms. There are many federally qualified health centers around the Valley that don’t require patients to show proof of citizenship.
Robbie Rodriguez, Equality California’s director of health, education and immigration programs, said the needs of undocumented patients are a little clearer to doctors, such as an interpreter or physician who speaks their language. The needs of LGBT patients are more nuanced, he said.
“What we get from service providers is, ‘I don’t want to offend anyone, so I don’t ask them.’ That leads to a lot of distrust and misunderstanding,” he said.
The training brought clinics up to speed on LGBT sensitivity.
Lisa Lewis, a psychologist at the Visalia Adult Integrated Clinic, said staff already were accepting of LGBT patients, but the training taught them proper terminology to ensure patients feel comfortable. The clinic lobby features many signs in Spanish. Staff are now looking to add a rainbow flag and LGBT-inclusive signs.
Lewis learned about medications such as the HIV-preventive pill pre-exposure prophylaxis, or PrEP. Lewis said she has referred patients to PrEP after the training and is looking into stocking it at the clinic.
“With the LGBT community, the ability to (articulate) the questions and the exploration of their health and their identity has become much easier for the staff,” she said. “I think they’re feeling much more comfortable exploring those issues with their consumers and making sure that we’re really able to identify their health needs.”
Training sessions ran from two to four hours and covered basic LGBT terminology, the difference between things like biological sex, sexual orientation, gender identity and gender expression, the importance of knowing who LGBT patients are and the dangers of such patients not coming out to their doctors. They also went over health disparities for LGBT people and the ways that clinics can create a more welcoming environment for their patients.
The session at the adult integrated clinic was one of about 90 held statewide, the vast majority in the San Joaquin Valley. Around 2,000 staff were trained, including administrators, management, nurses, doctors and health care enrollers.
The training has produced lasting changes at clinics that made LGBT issues a priority.
Madera County Public Health Department, whose staff participated in the training in July 2015, started by changing its intake forms to include a third option under the question of gender for people who consider themselves neither male nor female.
Deputy Public Health Director Gilda Zarate-Gonzalez said she also included the third gender option in a countywide community health assessment survey. Out of nearly 2,200 surveys, just four people indicated they are gender non-conforming. Even so, she considers it a victory.
“It was important for us to do it institutionally and to start formalizing our intent to be more inclusive,” she said. “It was a big shift in the way we do things in our department.”
Zarate-Gonzalez didn’t stop there. She said clinic staff began conducting more aggressive outreach for the HIV/AIDS program in nontraditional places, including migrant farmworker housing.
The county received a state grant for more outreach to the LGBT community and medication like PrEP. In March, the clinic will start including options on intake forms for patients to share their sexual orientation.
More substantial changes take time. Zarate-Gonzalez said the clinic has spent eight months looking for a doctor who is knowledgeable or willing to be trained in LGBT issues. She said they want to make sure the LGBT community has a medical home.
Barriers to health care
Access is the biggest barrier to health care for immigrants here illegally. Undocumented California residents make up the bulk of those without insurance.
Undocumented children up to age 19 have been eligible for full Medi-Cal benefits since last May. Medi-Cal is the state’s version of Medicaid, which helps low-income people pay for medical care.
Undocumented adults can get primary care at federally qualified health centers at little to no cost. Fresno County supervisors in 2015 voted to dedicate a one-time allocation of $5.6 million to cover the costs of specialty care, such as heart procedures and cancer treatment for undocumented adults.
California officials last month withdrew their request to sell unsubsidized insurance plans to people who can’t prove they’re here legally. Sen. Ricardo Lara said he doesn’t trust the Trump administration to protect people’s privacy and health.
LGBT people face a similar fate. Research shows LGBT people are less likely than others to have health insurance. Numerous health disparities, including substance abuse and mental disorders like depression, affect LGBT people, in part because of discrimination and a lack of culturally competent care.
A 2012 report by the Fenway Institute, a national center for LGBT health research and education, says the long history of anti-LGBT bias in health care still shapes the behavior of people seeking aid and their access to care, despite increased social acceptance.
Clinical training about LGBT health is scant. A 2011 report in the Journal of the American Medical Association says a median of five hours was devoted to LGBT issues at North American medical schools.
Equality California’s goal is to fill the training gap. Rodriguez said the organization can’t solve all of the LGBT community’s unique and complex health disparities, but it can improve clinic care.
“If the patient has a better relationship with their provider, they’ll feel more comfortable going back,” he said. “Overall, health will improve because of that.”
Long term, Equality California – and Valley advocacy groups like Building Healthy Communities – had been advocating for access to health insurance for undocumented immigrants, until President Donald Trump’s election. Rodriguez said the organization is now at a standstill because of the administration’s moves to repeal the Affordable Care Act and crack down on illegal immigration.
Ojeda considers himself privileged. He is about to start a job as a campaign coordinator with the advocacy group Californians for Justice and soon will have health insurance for the first time in his life.
That will change everything. He got tested for STDs and HIV early last year but doesn’t remember the last time he had a regular checkup from a primary care doctor.
Ojeda said training is a good start, but for the rest of his community, the issue won’t be fully resolved without increased access to health care.
“Doctors can be as trained as they want,” he said, “but our first instinct isn’t to go to the doctor – it’s a home remedy or over-the-counter medicine.”
Clarification: Building Healthy Communities continues to campaign for health insurance for undocumented immigrants.