Taking Pride in Health Care: And It's Good for Business

Through the efforts of its equity committee, Grace Cottage was honored last year as an LGBTQ+ Healthcare Equality Top Performer by the Human Rights Campaign Foundation. Seated, from left: Dave King, community member; Jen Newman, senior director of human resources; and Brian Mayher, registered nurse. Standing, from left: C.J. King, grantwriter; Scott Heller, community member; Sarah Howard, staff/nurse educator; Doug DiVello, CEO; Andrea Seaton, senior director of development, marketing and community relations; and Lisa Eaton, chief nursing officer. Photo: Maia Segura.

by Maia Segura

When Hurricane Maria ripped through Puerto Rico in 2017, Adriana, her husband, and four biracial children found more than buildings and city streets in the wreckage. The structure of the economy was in turmoil, including basic services for children. 

This became an even greater concern as one of their elementary school aged children began to identify as gender nonbinary. “The one thing that we couldn’t get past was the fact that we knew that our child was going to struggle in the educational and health systems on the island, and we were trying to find a better place for them,” Adriana said. In the family’s quest for a safer place, Vermont seemed to be the greener pasture to ensure their child’s wellbeing.

But when the family arrived in Southern Vermont two years ago, they didn’t experience the soft landing for which they’d hoped. Their initial experiences with a pediatrician left them feeling frustrated, and their child feeling uncomfortable and anxious. 

“We were treated poorly, and we weren't sure exactly why. We are a Puerto Rican family. I think that the assumption was that we didn't have a certain degree of education, or we didn't know what we were doing with our kids. It really felt that way,” said Adriana. She then felt in urgent need of finding a healthcare provider that was both aware of cultural differences and accepting of their nonbinary child.

That’s when a friend suggested Grace Cottage Family Health & Hospital, an independent non-profit healthcare center located in Townshend, VT. The facility includes a hospital, emergency care, rural health clinic providing primary care, and mental healthcare, among others. And last year, Grace Cottage was one of just two facilities in the state that were awarded “LGBTQ+ Healthcare Equality Top Performer” in the Human Rights Campaign (HRC) Foundation’s Healthcare Equality Index (HEI). The HEI evaluates and scores healthcare facilities on detailed criteria falling under four areas: foundational policies and training in LGBTQ+ patient-centered care, LGBTQ+ patient services and support, employee benefits and policies, and patient and community engagement. Grace Cottage was among only 28% of the 900 participants across the US which earned the highest HEI designation. 

“It’s been a really great experience. When we talked about our child being gender nonbinary, immediately there were conversations about what we needed to do, if, at any point, we were going to need gender affirming care. The staff in general are very respectful,” said Adriana. “I think that it meant a lot for my child to come in and see the information about the LGBTQ+ clinic, and small things like an LGBTQ+ flag, and have staff ask for their pronouns. That's significant for someone who is in a process of cementing their identity.”

The experience with Grace Cottage was a turning point for the family. This was the Vermont for which they’d hoped, and their child began to settle in. “The safe spaces in this area, including Grace Cottage, have helped them come out of their shell and feel more confident. They feel good. They are able to express themselves and show up in the world as they are. The difference is del cielo a la tierra [translation: from heaven to earth], and that’s a big difference.”  

Adriana’s family’s experience at Grace Cottage is not by chance. The organization started its equity work in 2018 with just two people on the LGBTQ+ Committee: Chief Medical Officer George Terwilliger, MD, and Family Nurse Practitioner Summer Burch, FNP. Almost immediately they were joined by a new nursing staff member, Brian Mayher RN, BSN, CHPN, CRRN, who moved from Whatley, MA, to live with his partner Donald, who is also a nurse at Grace Cottage. 

Photo: Grace Cottage registration employee Alison Bills is often the first person LGBTQ+ patients meet to indicate an intentionally safe  and welcoming culture at the facility. Photo: Maia Segura.

Grace Cottage registration employee Alison Bills is often the first person LGBTQ+ patients meet to indicate an intentionally safe 
and welcoming culture at the facility. Photo: Maia Segura.

“I wanted to join right away because I think it's so important,” said Mayher. After keeping the committee moving forward through COVID, the trio felt that it was important to expand the focus from LGBTQ+ to include all groups that may be inequitably served. As the scope grew, so did the number of committee members and the commitment from the top. The Equity Committee now includes members at all levels of staff: HR, marketing and community relations, and nursing staff, as well as non-staff members from the community, and representatives of neighbor Valley Cares which provides affordable housing and supportive services to the elderly. 

“There's a buy in from all the upper management,” said Mayher. “That really means a lot to me. If different people on different levels are involved, you can make a difference. It just feels real. We're not just talking about stuff. We've been able to make some changes.”

Grace Cottage currently offers an array of gender-affirming services including primary care for adults and children, affirming counseling and psychiatric services, among others. The Equity Committee work has been responsible for improving LGBTQ+ awareness and access, providing staff trainings, and other initiatives such as making changes to their medical record database to accommodate a variety of pronouns and gender, beyond gender assigned at birth. This attention to detail extends into staff culture as well as interactions with patients. But it took work to get there. For Mayher, it prompted him to start asking the pronouns of his coworkers, as well as patients. “As a group we’ve learned we can have the best intentions, but you have to be open. Personally, employees have expressed appreciation when I’ve asked [their pronouns] because being gay doesn’t make me an expert [in the LGBTQ+ spectrum],” he said. “And all of us learning together has helped me approach patients and their families more aware than I would have if I wasn't part of this committee.”

Andrea Seaton is the Senior Director of Development, Marketing, and Community Relations at Grace Cottage, as well as being a member of the equity team. “One of the things I value most about our equity team is that our effort has been home-grown,” said Seaton. “We didn’t have the funds, nor the desire, to hire an outside consulting firm to move us along this path. We’ve done it all from within, which makes it resonate more, I think, and it runs deeper in our culture, as a result.”

Mayher senses a cultural shift among LGBTQ+ staff.  “I think partially because of our work in equity initiatives, a lot of [staff] are openly identifying that they're trans or gay or lesbian, or any number of different pronouns,” said Mayher. “I think that’s because we're okay here, and accepted, and…it feels very natural and normal.” 

Juliette Carr, FNP, RH (AHG) is a family nurse practitioner at the Grace Cottage primary care clinic who has also embraced the culture and call to action to ensure that the environment at Grace Cottage is welcoming for everyone who walks in. This may include being literate in specific healthcare risks for the LGBTQ+ community or addressing intersectional issues affecting healthcare access and helping to combat complex mental health issues.

Sometimes it’s as seemingly simple as making sure that a person is called by the correct name. Which, as it turns out, is not so simple. “Here's an easy thing that I do,” said Carr. “If somebody goes by a name that's different from the name on their medical record, when I give them their follow up slip, I will write a note to registration to change their name in the computer system. So, the next time they show up, whenever they call the clinic, or anytime someone sends them a message at the top of their medical record it says their legal name, and then what they want to be called - right there together - so that nobody makes that mistake again.”    

These efforts have a positive impact, especially on new patients who sometimes arrive anxious or are expecting a harmful encounter based on previous medical-related trauma.  “Before they even encounter me, hopefully they've made it through a couple of layers of people who are working to make them comfortable,” said Carr, who notes that she sees patients that travel up to two hours for an appointment and from multiple states. Distance is just one factor that may make it difficult for patients to come in. Debilitating anxiety can be caused by registering as a new patient, and then compounded by sometimes having to wait months for the first appointment. Other factors such as having to take time off work for the appointment and navigating nerve-wracking road construction on the journey can add to the challenges. “The whole process of making it into my exam room can be triggering and stressful for people,” she said. 

As a result, the process to make a patient comfortable and trusting can take more time and multiple visits.  “I can think of a new patient just a couple of weeks ago who came in so anxious that they were shaking, and by the end of the visit was still really ramped up,” said Carr. “But clearly, the other shoe that they were expecting to drop, never dropped. When they came back a week later to follow up, they were different.  They were so much calmer. And then the third time, they were their normal selves, because by that point, they had worked their way through the feeling that, ‘Whatever bad thing I was expecting someone to say to me hasn't been said yet... whatever way I'm expecting to feel alienated and uncomfortable hasn't happened.’  Eventually, people get comfortable enough to really confide, but that takes extra time when people have a history of medical trauma.  We're building trust incrementally by consistently being welcoming and safe.” 

LGBTQ+ in Vermont

About 5.2% of the population, or around 30,000 people, identified as lesbian, gay, bisexual, or transgender in Vermont in 2022, ranking seventh in the nation (after holding first place in 2017), with 19,000 in the workforce.  But even with significant representation in the state, LGBTQ+ people may experience higher rates of income and social challenges. According to the Williams Institute, LGBTQ+ people in Vermont are somewhat more likely than non-LGBTQ+ people to be unemployed, food insecure, and have an income under $25,000 annually, all of which may contribute to health disparities.

A Vermont State Health Assessment in 2018 found that LGBTQ+ adults were almost twice as likely to be diagnosed with depression compared to non-LGBTQ+ adults. The report also found that:

LGBTQ+ adults are slightly less likely than heterosexual adults to have a usual primary care provider, or to have visited a doctor or a dentist in the past year. They are, however, twice as likely as heterosexual adults to delay care, or be unable to get care due to cost. 

The report goes on to say:

A greater proportion of LGBTQ+ Vermonters report worse health than heterosexual Vermonters. Lack of access to quality, affirming healthcare is a concern expressed by many LGBTQ+ Vermonters. Many experience discrimination or find themselves having to educate their healthcare providers about their particular health needs.

Photo: Grace Cottage badges include employee pronouns in an effort to create a more inclusive culture. Photo: Maia Segura

Grace Cottage badges include employee pronouns in an effort to create a more inclusive culture. Photo: Maia Segura.

However, the report also found that, “Many Vermonters have found a sense of belonging through LGBTQ+ welcoming organizations and groups, while others have found connectedness through informal networks. Having a positive and supportive community can build resilience and connections.”

Within the health spectrum, LGBTQ+ people are also at higher risk of problems arising from drug and alcohol abuse. Recognizing that there was a need for specialized care for LBGTQ+ people in the areas of mental health and substance abuse, the Brattleboro Retreat launched an adult in-patient LGBTQ+ program in 2009 – the first of its kind in the region. 

Karl Jeffries, MD, Chief Medical Officer at the Retreat, explained that at the time the organization was looking for ways to expand and develop niche programs to help distinguish itself. Decisionmakers, said Jeffries, “recognized that this is important, and an opportunity to do some really great work.” 

“Many of our patients who identify across the spectrum, when they are accessing acute mental healthcare treatments, run into a lot of obstacles that can get in the way of full recovery, or impact the process,” said Jeffries, who is, himself, gay. For example, homophobic or transphobic comments made by peers during a group session can shut down people while they are most vulnerable. “They're at a place where we want them to become authentic, true, and open,” said Jeffries. “If you're afraid, it's difficult to do that. It's about creating a safe space to heal in a way that feels safe across the board and feels safe in terms of acceptance of opportunities to grow.”

The program features a separated 15-bed unit with gender-neutral bathrooms and showers, co-ed programs that welcome all expressions of gender, and carefully selected staff at every level highly trained in the ways in which sexual orientation and gender identity can shape people’s lives. ID bracelets intentionally support patients in their current identities as well as including the criteria for safe management and healthcare. LGBTQ+ programming is also sometimes built into group therapy work. “We approach it through a frame of understanding of how it might influence, or might be impacted by someone's gender, sexual identity, or other aspects of just being queer in this world,” said Jeffries. “It's all aspects of what might contribute to that safe space, all the way down to an understanding of how that actually impacts individualized treatment.”

The effort clearly impacts some patients. Jeffries, who worked in the LGBTQ+ unit before later transitioning into an administrative role, notes a patient he treated several times who demonstrated self-harming behaviors and profound depression. 

“Coming to the hospital probably the third or fourth time in a period of eight months, they acknowledged that they were starting to feel like [the LGBTQ+ unit] was an okay place to start to explore something that they had long wanted to explore, but they'd never said out loud. Then they began to speak about their struggles with gender identity,” said Jeffries. “As that process happened, they recognized that the vulnerability of going into that space is what contributed to a lot of the unsafe things that were happening when they were outside of the hospital. This was a place that they could begin to explore it and be safe with a community that was also able to support the family… But it really got to what was going on in the months before when the person was fighting themselves, (feeling) hopeless, and ending up in the hospital repeatedly. That's an example of what the power of that space could be and can be.”

The Veterans Administration White River Junction Healthcare (VA WRJ) is another facility that has been a leader in Vermont LGBTQ+ healthcare programming. VA WRJ is the only other Vermont facility that earned HEI “Top Performer” status in 2022, after first receiving “Leader” status in 2015, consistently ranking highly since. But the work to initiate critical resources for LGBTQ+ Veterans at VA WRJ began in earnest in 2013 to identify and resolve barriers to employment, as well as advocating for compassionate healthcare for patients with intensive staff training. 

The VA recognized that specialized care for LGBTQ+ Veterans is an acute need. According to the US Department of Veteran Affairs, “Sexual and gender minority Veterans have faced stigma and discrimination, which can affect their mental health. Lesbian, Gay, and Bisexual Veterans are two times as likely to receive a diagnosis of an alcohol use disorder and are five times as likely to receive a diagnosis for Post Traumatic Stress Disorder (PTSD).  Additionally, Transgender Veterans have significantly higher rates of serious mental illness, suicidal ideation, PTSD, and major depression than non-identifying Transgender Veterans.”

Although the VA did not have care-barring policies for LGBTQ+ Veterans, the US Military did. In 2011, when “Don’t Ask, Don’t Tell” ended, the Veterans Health Administration established the Office of Health Equity to reduce health disparities in vulnerable populations, including LGBTQ+ Veterans, by raising awareness, providing training, and advocating for healthcare system changes. One of the tools that the Office has used to guide them is the HEI Index survey. Now the LGBTQ+ Health Program includes national and local programming that supports staff and Veterans, including instituting an LGBTQ+ Care Coordinator at every VA care center.

Salissa Wahlers MSW, LICSW is the LGBTQ+ Care Coordinator at VA WRJ. In addition to training, she says, “Hospital culture is geared towards inclusivity with safety symbols such as rainbow ID lanyards, informational posters in hallways, rainbow awareness items in provider offices, etc.” While not all Veterans with LGBTQ+ identities will need her services as the program coordinator, they are able to come to her for support or information if they wish, and VA staff may refer a Veteran to her if there are specific resource questions. The program has grown to include medical care, cancer and STI screening, mental healthcare, and gender-affirming care, among other services. 

The exact number of LGBTQ+ Veterans served by the VA WJR is unknown since the VA only started to systematically collect this information last year. As of 2022, VA patients can enter and edit their “Self-Identified Gender Identity” and “Sexual Orientation Identity,” as well as their preferred name into their medical records on the VA website without going through a staff person, giving them more choice and control over their healthcare information. “The care team can then tailor care to that particular Veteran and address any known health disparities and needs,” said Wahlers.  

The efforts have an impact. “I have received positive feedback from Veterans that they appreciate the ability to be themselves in their healthcare within the VA, when many were not able to be out during their respective service periods,” said Wahlers. She also noted that when some LGBTQ+ patients come in for care at the VA, it “is sometimes the only safe space some Veterans have to be themselves in a public setting.”

VA WRJ’s commitment to the LGBTQ+ community extends beyond the care center doors. According to Wahlers, “VA staff have participated in both the local WRJ and Burlington PRIDE parades and festivals and plan to do so again this year. It is wonderful to see Veterans and fellow community members at these events and demonstrate the commitment that the VA has to healthcare for all Veterans, as well as collaboration with our community members.”

In addition to Veterans, older LGBTQ+ people face unique challenges. Three million LGBTQ+ people are 55 years or older, and that number is expected to more than double by 2030, according to SAGE, which provides advocacy and services for LGBTQ+ elders. LGBTQ+ elders are twice as likely to be single and live alone, compared to non-LGBTQ+ elders. They can feel isolated, and sometimes do not have the same level of support from family as non-LGBTQ+ elders. They have friend networks, but friends are aging at the same rate and, at some point, may not be able to contribute to care for one another. “Most older people experience at least some of these issues, but they are compounded for LGBTQ+ elders due to lifetimes of facing stigma and discrimination, harassment, a lack of access to culturally competent service providers, and thin support networks,” SAGE reported.

Scott Heller and Dave King opened Newfane’s Frog Meadow Farm B&B and Massage Oasis catering to gay men in 2007. They celebrated their Civil Union in Vermont in 2001 and were later married on Cape Cod. For 18 years, they have hosted guests who are attracted by Vermont’s reputation as a gay-friendly destination.  Over the years, over a dozen aging guests have made Vermont their permanent homes. But these new residents often find themselves anxiously seeking gay-friendly services, particularly in healthcare. 

As community member representatives on the Grace Cottage Equity Committee, it is an easy referral for them to send new arrivals to Grace Cottage for safe, welcoming healthcare for aging gay men. “Without that comfort level, people don't go out and seek healthcare. Their health suffers and lives are affected,” said King.

But taking the next step to find senior housing or managed care facilities can be particularly difficult and anxiety-inducing as, SAGE reports, 70% of aging LGBTQ+ people report a fear of having to “re-closet” themselves when seeking that housing. When it comes time for King and Heller to consider their own future housing, the couple has been inspired by Valley Cares in Townshend. 

Valley Cares sits on a piece of land that was donated to Grace Cottage in 2004, by Warren Kronemeyer.  Kronemeyer and his life partner of 58 years, Leon Ingall, were locally beloved owners of Warlé Antiques located in the historic brick home that now stands at the center of Valley Cares. As the story goes, Kronemeyer, having survived Ingall who passed away in 2002, donated the property in exchange for safe healthcare and housing through the end of his life – a bargain which was kept. In 2005, Grace Cottage donated the house and property to Valley Cares for their eldercare living project. Valley Cares opened in 2007, the same year Kronemeyer died. A commemorative plaque and eternal flame sconce was dedicated in his honor last year, and community garden on the grounds was dedicated in his memory in 2018. 

“As I learned the story of Valley Cares and how it came to be, it made me want to help tell that story,” said Heller. “And it made me think when we retire, we don't need to move and find a place to live and hope that there's a graduated eldercare facility nearby. We have it here.” Others may not be so lucky. SAGE provides some referral resources for eldercare housing, but the lists are not extensive, and a search for these services in Vermont came up empty.

Solid referrals for equitable care for LGBTQ+ people in Vermont can be difficult, in general. But the Vermont Diversity Health Project (VDHP), supported by the Vermont Department of Health, and powered by the Pride Center of Vermont, is making it easier. VDHP maintains a searchable database of about 300 providers who are committed to equitable care, including LGBTQ+ people working in the field. According to Kell Arbor, Health and Wellness Director at Pride Center of Vermont who is queer trans and goes by the pronouns “they/ze”, Pride Center of Vermont was the last keeper of the “Gay & Lesbian Yellow Pages,” a resource for LGBTQ+ people to find safe, friendly services and to support each other. So it was natural for them to administer the medical provider database. “The healthcare provider piece really bloomed out of sheer community need,” said Arbor. “We don’t know how to find each other.” 

VDHP also facilitates trainings for healthcare providers. “The database is a great, searchable resource to get the network going and get the info to people,” said Arbor. “But for me, it's the trainings that really feed the database. This is about creating a cultural shift [for] healthcare in our region, to connect people to providers, [and] to connect providers to each other.” This goal was recently achieved when Pride Center VT co-hosted the Vermont LGBTQIA+ Healthcare Summit with Out in the Open and Outright Vermont to bring together healthcare providers and members of LGBTQ+ communities to share best practices and storytelling to strengthen understanding and relationships. “Part of what the health summit gave us this year was our lofty goals of how to create a container so that we can connect to each other in a safer way, but also to get the information out. I could see us all moving forward as a region,” said Arbor. 

Arbor identifies multiple hurdles standing in the way of systemic change including norms in language. The cultural tendency to sort strictly into male and female can lead to providers using incorrect pronouns and misgendering, potentially causing harm to patients. “One of the things we talk about is not using ‘preferred’ [when referencing pronouns]. It's what [people are] using. It's not a ‘preference’ or a ‘choice.’” 

The binary nature of computer data systems can significantly compound the problem by not providing fields that capture critical information like current and past, or “dead” names, gender assigned at birth which can be different from current gender identity, as well as pronouns.  Not having a place to catch and store this information can lead to uncomfortable and harmful mistakes. Providers over-apologizing for errors can sometimes compound the problem. It can put a patient in the awkward position of having to comfort the provider. “When it keeps happening, and we keep talking about it, it's even more harmful over time,” said Arbor. 

For Charlie, who is a queer trans person in their early 20’s, failure to capture and share this information can trigger a string of harmful events.  

When I walk into my healthcare place, especially if I've been referred somewhere that’s not my normal primary care provider, I never know how to introduce myself because the way that health records in the system work is that my ‘preferred’ name doesn't show up for these people,” said Charlie. “It is easier for me to sometimes act like I'm not a queer person. Not that I'm necessarily acting any differently but using my ‘dead’ name and stuff like that. Because then you have to come out to people over and over and over again as queer. Oftentimes, that can end up with the provider being, ‘Oh my gosh, so sorry.’ And then it's often on me to be, ‘Oh, no, it's okay,’ you know, out of politeness sake. Sometimes it’s easier to not say anything at all, than [to] have to take the step to say, ‘No, I actually go by Charlie...’ Once you do that enough times, you don't always have a lot of energy to draw from, especially if you are seeking healthcare for an issue that you're having.” 

Charlie goes on to say, “I think oftentimes, there can be a sort of othering aspect to inclusiveness in a way that you're trying hard, and it's well intentioned. But it is making me feel outed in a way, like it's too much. I want transness and queerness to be treated as a normal thing.”

Misgendering coupled with a lack of medical training can cause physical harm to patients. Arbor has experienced this firsthand. Since Arbor was assigned female at birth, they had to seek care at women's health centers, but those centers did not screen for STI’s like HIV. “I went about a decade with an undiagnosed HIV diagnosis. And then I had a near death experience with AIDS at the end of 2009,” said Arbor. Traditionally, HIV tests were only given to populations that were assumed to contract HIV, like gay men. “I was given stories that women don't get STIs when I asked for full STI screening, so I was falling through all of these nets,” said Arbor. 

The lack of collection of sexual orientation and gender identity (SOGI) can create blind spots for individual care as well as in data needed to create standards and polices.  

This will be critical for patient-centered treatment plans and to allocate resources at Brattleboro Memorial Hospital as the organization moves forward with a new LGBTQ+ focused primary care clinic. “We want to ensure that we can provide the healthcare that everyone deserves,” said Kathleen McGraw, MD, Chief Medical Officer at Brattleboro Memorial Hospital (BMH), who lives in Brattleboro with her wife. “If we don’t ask the questions, we can’t do that.” Like Grace Cottage, BMH has been successful in modifying its medical records system to capture more of this information. 

On a grander scale, lack of capturing this information equates to a lack of critical data for healthcare and social policy. According to a US Office of Management and Budget report, “Measuring sexual and gender minority (SGM) populations in Federal surveys improves understanding of SGM populations and supports evidence-based policymaking.” SOGI collection was addressed for the first time by the 2020 US Census to help identify same-sex couples and their families. However, the survey did not address sexual orientation or gender identity. 

A brief produced by Minnesota’s State Health Access Data Assistance Center (SHADAC) in 2021 reported, “Thirteen million people identify as part of a sexual or gender minority (SGM) in the United States, with an estimated 1.17 million who have Medicaid as their primary source of health insurance coverage. While COVID shed a unique light on the need for more equitable health data collection across all populations, one area in which efforts are still falling short is sexual orientation and gender identity (SOGI) data – especially for those covered by Medicaid.” 

Additional systemic barriers include the cost of the US medical care system. According to the Opportunity Institute, the U.S. health-care system is the most expensive in the world – but that does not equate to higher quality healthcare. The institute reported that, “Americans spent more than $11,000 per person on healthcare in 2018, yet we still have higher rates of chronic diseases such as diabetes, cancer, and heart disease than our peer nations, and millions can’t afford to see a doctor for basic care. Insurance premiums and other out-of-pocket costs for people seeking care, such as deductibles and co-insurance, go up year after year, fueled by rising specialty provider reimbursements, executive salaries, and profits for hospitals and drug makers.” 

The culmination of these barriers can lead to skipping necessary care which can result in long-term health challenges, expensive emergency room visits, and increased costs for the whole system. In the meantime, politicians in many states are advancing anti-LGBTQ+ laws that further strain the system.

Politics of Exclusion 

As of May 2, the ALCU reported that during the 2023 legislative session alone, a total of 128 bills targeting LGBTQ+ healthcare rights were introduced in 33 states. These bills target access to medically-necessary healthcare resources like Medicaid for transgender people, among other barriers to healthcare for LGBTQ+ people. Many of these bills ban affirming care for trans youth and create criminal penalties for healthcare providers who administer this care. Of the bills introduced, 76 are advancing, 16 have been passed into law, and only 32 have thus far been defeated. 

The bills have a chilling effect for LGBTQ+ people. “I’ve heard these referred to as ‘genocide’ within the community,” said BMH’s McGraw. “The bottom line is that this is not a ‘behavioral’ thing. It’s a deeper identification of self. Laws won’t change that complex, deep sense of self.” 

Here in Vermont, during the 2023 session legislators passed two “shield” laws, establishing a slate of protections from liability originating from out of state for both providers and seekers of gender affirming healthcare, as well as those seeking or administering abortions. Both were signed into law by Governor Phil Scott on May 10. According to the ACLU, the new laws, include “enabling ‘claw back’ lawsuits, protecting patients’ and providers’ personal information, safeguarding providers’ ability to practice medicine when offering legally protected healthcare, and prohibiting Vermont officials from assisting another state in pursuing criminal or civil liability for providers.” With the protections provided under these laws, the practice of patients coming from miles away for LGBTQ+ safe, inclusive healthcare is likely to bring even greater numbers of patients to Vermont from afar.

Economics of Inclusion

In addition to creating anxiety and fear, these laws have a negative impact on the economy. According to a 2021 Al Jazeera news story, “Some economists estimate countries are losing billions of dollars a year due to homophobia and exclusionary laws and practices.” Access to jobs, education, and healthcare, and exclusion from society which can affect mental health, all create barriers to prevent people from fully participating in the economy, causing “a drag on economic growth,” which affects the whole economy. This gets played out on a global scale. 

Closer to home, the Williams Institute did a research study on the legal landscape affecting LGBTQ+ communities and the economy of Georgia which is home to over 300,000 LGBTQ+ adults and 58,200 LGBTQ+ youth. According to the study, “In Georgia, LGBT people face a challenging legal landscape and social climate, which contribute to stigma and discrimination against LGBT people in the workplace, at school, in housing, and in public life. Stigma and discrimination have been linked to negative economic impacts on governments, businesses, and the economy.” The study estimated that “workplace and housing discrimination against transgender people costs the State of Georgia approximately $1,048,000 in state Medicaid expenditures and $477,000 in homeless shelter expenditures each year,” but reducing disparities in issues where LGBTQ+ people are disproportionately affected, such as depressive disorder and smoking, could create a net benefit to the state of up to $250 million each year. 

Research backs up the economic benefit of inclusion. In a 2019 study, Badgett and other researchers found that, “an extra point on the Global Index on Legal Recognition of Homosexual Orientation, which consists of eight categories of legal recognition and protection, was associated with an increase in real GDP per capita of about $2,000.” Additionally, nations that are more inclusive are better able to recover from the economic blows like the COVID-19 pandemic, as well as brace for future disturbances.

LGBTQ+ inclusion is not only good for governments and economies, say researchers, but it is also good for businesses. Open For Business is a coalition of dozens of leading global companies (such as American Express, IBM, and Microsoft) dedicated to LGBTQ+ inclusion and tasking itself to “present the business rationale on global LGBTQ+ inclusion: successful, enterprising businesses thrive in diverse, inclusive societies and the spread of anti-LGBTQ+ policies runs counter to the interests of business and economic growth.”

Open for business research found that, “Stronger financial performance flows from the increased ability of LGBT+ inclusive companies to attract and retain talent, to innovate, and to build customer loyalty and brand strength.” Of these, closest to home are employee attraction and retention.  According to Jon Miller, one of the authors of the study, companies that are LGBTQ+ inclusive are “better able to attract the most talented people and then retain those talented people.” 

Karl Jeffries, Brattleboro Retreat CMO is an example of this.  Jeffries, who had a private LGBTQ+ specialty outpatient practice in San Francisco moved to Vermont specifically so that he could work in the LGBTQ+ unit at the Retreat. 

“My husband and I moved across the country with our two boys. I don't know that it would have been Vermont if it hadn't been [for] this job [that] was very attractive to me,” he said. For a decade, Jeffries’ talents and passion for the organization encouraged him to stay at the Retreat and allowed him to rise in the ranks to CMO. 

Photo: Kronemeyer Courtyard at Valley Cares senior housing in Townshend commemorates Warren Kronemeyer, who owned and operated a business with his partner of 58 years, Leon Ingall, before donating the property that would become Valley Cares. Photo: Maia Segura

Kronemeyer Courtyard at Valley Cares senior housing in Townshend commemorates Warren Kronemeyer, who owned and operated a business with his partner of 58 years, Leon Ingall, before donating the property that would become Valley Cares. Photo: Maia Segura.

Perhaps more importantly for the organization, creating an inclusive culture has impacted employee retention. “[That] can have a really big impact financially for an organization like us. The people who work on that unit are very passionate about it. They've been there for a really long time…It's something that the entire hospital feels great about. I think it has a profoundly positive impact in that regard,” Jeffries said. 

Across Windham County at Grace Cottage, Brian Mayher has no intentions of moving on in a labor market that is hot for his skills, partly because of Grace Cottage’s culture of inclusion. He attributes some of the ability to create an inclusive environment to the scale of the operation. “We're the smallest independently owned hospital in the country. Being independent, I think it allows us to make our own decisions,” said Mayher. “It doesn't feel how it might have felt before, or in a larger place where it's not talked about or isn't something that people are trying to change. It made me more comfortable here. And sometimes I even take it for granted. It's almost a non-issue for me being a gay person here because it's so normal, [and] more people can be out,” he said. “I think a lot of times, people in the LGBTQ community can be around. But if they're not [openly identifying], you might feel alone. Because we aren't afraid to identify here, we don't feel as alone.”

It’s Mayher’s hope that people in other organizations will understand that change is possible, but it takes time and commitment. “You can make changes in your organization, whatever that may be, if you just stick with it, even if it's two or three people. It's not like everything's going to happen at once. There was a long time [at Grace Cottage] where it was just two or three of us, and now there's a bunch of people outside the community, and outside the organization as well. You have to look back sometimes to realize that you've made a lot of changes. But it is worth it.” 

Charlie agrees that long-term change takes communitywide effort. “True justice and steps towards inclusivity require that people with power - cis[gender] people - use that power to advocate for queer people. Because it takes a lot of work to just be a queer person in the world, especially with the horrific stuff going on about trans healthcare,” said Charlie. “It's a lot to shoulder the burden of advocating for myself in the healthcare system when all of these things are…happening. These things directly affect me. So, I don't have a choice but to stand up for myself. People in places of privilege do have a choice and often choose not to do anything. So, it is the power of all of us together that…creates change.” 

Kell Arbor at Pride Center of Vermont believes that although Vermont has an advantage in small scale and a strong history of inclusiveness, there is still room to grow and innovate to bring more economic power to equitable, inclusive efforts. “We have, for over 25 years, served lesbians and gays pretty darn well in Vermont. But, [we need to] recenter ourselves in the groups that we haven't been serving well - trans, queer, intersex, asexual, and HIV positive folks - to look at the gaps and serve those broader needs of people of color and people with disabilities,” said Arbor. “We're an interconnected state. We have a lot of wealth as a small state. And if we could do high impact regional things, like a health provider database…it could be a big money pot that somebody runs. We're creative. And [outsiders] already see [Vermonters] as weirdos. So, we can do whatever we want.”

Maia Segura is a writer from Southern Vermont.