Changed Hearts And Minds – A Personal (Ongoing) Journey To Better Understanding LGBTQ+ Equity Issues

Last week, Supreme Court Justice Clarence Thomas opined that we should revisit several major Supreme Court decisions, including Obergefell v. Hodges, which legalized same-sex marriage. This startled me. But it also moved me to reflect on my own past. And some of these recollections are painful to look back upon.

Two decades ago I supported the official Republican platform and President George W. Bush’s public call for a constitutional amendment defining marriage as between one man and one woman. I can firmly say I was wrong then, and it would be a major step backwards for this country to even consider relitigating that issue in the future. Indeed, we have seen major, positive cultural and attitudinal shifts on LGBTQ+ issues for the country — and a parallel personal journey of awareness, enlightenment, and growth for me.

As Americans, we can all agree there’s been sizable cultural change in our nation over the last 20 years. Looking back on my time as a member of the United States Senate at the turn of the century, and later as its Majority Leader from 2003–2006, many of the issues we voted on and beliefs we held then – including my own – are totally out of step with today’s more enlightened understanding and prevailing viewpoints. And while many feel today’s culture wars may be reaching a boiling point, we should recognize that amidst current partisan infighting, we have also made huge, generational progress, always recognizing that much more must be done.

Just look at the change over that period. In 2003 only 32% of Americans were in favor of gay marriage, whereas 59% were opposed. Fourteen years later, those numbers were reversed, with 2017 Pew Research Center data showing 62% of Americans in support of gay marriage, with just 32% opposed (support is even higher today, reaching 71% in favor in May 2022). Thankfully and rightly, there has been a monumental shift in viewpoint and attitude. Like so many others, I am one of those Americans whose views have radically changed. I have realized over time my public stance while in Washington was wrong and misguided, and clearly at odds with my fundamental conviction that every human being should be treated respectfully and equitably and fairly. My trajectory has been an arc of increasing awareness, sensitivity, and education. And I know that growth will continue.

As disturbing as it is looking back, here is my journey. Early on, I had been raised in a conservative tradition in the South and later became a transplant surgeon treating patients equitably, irrespective of gender, color, creed, or socioeconomic status. On a personal level, my closest friends did not include any openly gay individuals, and as a result I never thought much about the unfair stigma that people who identified as a part of the LGBTQ+ community had to endure. Then came election to the Senate where public stands are the rule. My first exposure to gender policy was The Defense of Marriage Act (DOMA), signed into law in 1996 by President Bill Clinton. It was supported overwhelmingly by both parties in Congress, including myself, defining marriage as between one man and one woman, thus allowing states to deny same-sex marriages. In retrospect, for me this was mistake number one. Then came the early 2000s, when the Republican platform and President Bush supported a constitutional amendment to ban gay marriage. My support here was mistake number two.

I have no excuses. I just did not acknowledge or understand at the time what seems so clear to me now. On my watch, our nation’s policies made it harder for our LGBTQ+ citizens to care for their loved ones when sick or hospitalized (not recognized as next of kin), harder to build a family of their own — through adoption, fostering, surrogacy, or other methods of assisted conception — and impossible to participate in private and federal benefit programs for spouses. And the policies led to people being treated differently in so many other social and economic situations. Civil unions were a “separate but equal” approach, and clearly conferred a second-class status. These policies were discriminatory and hurt vulnerable people unnecessarily.

I retired from the Senate in 2006, left Washington, and actively reengaged in my local community in Nashville. While doing so I became increasingly aware of LGBTQ+ friends affected by our nation’s discriminatory policies. I became closer friends with couples who were dearly devoted to one another and simply wanted the ability to celebrate their love and union in the way that so many Americans take for granted.

So, my journey progressed, and I grew energized by the world around me. I felt an obligation to learn more, to uncover the realities, to generate new information on LGBTQ+ equity issues, and to share broadly what I learned to help others better understand issues they, like me earlier in life, may have been oblivious to. Thus I began to purposefully identify and investigate, write and publish on what I learned, and conduct podcast interviews for a national audience on the inequities experienced by vulnerable and minority populations, and specifically the LGBTQ+ community.

In my exploration I came head-to-head with the health ramifications of the discriminatory policies as well as the daily stressors experienced by our LGBTQ+ population when treated so unfairly as a different class of citizen. For decades, homosexuality was classified as a mental illness or disease, with it not being completely removed from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders until 1987, and was listed in the World Health Organization’s International Statistical Classification of Diseases until 1990. This seems shocking to think of now, but it is a painful reality many had to live through. Our slow reckoning in health and healthcare meant many were unfairly judged, with some suffering through conversion therapy that is wrong, mentally cruel, and has no basis in science. While we’ve made progress in the medical field, LGBTQ+ individuals still experience unconscious bias and at times even intentional discrimination in the healthcare system today, as I came to learn.

Here are some examples from my personal journey:

Research and identification

Seven years ago I founded the nonprofit community collaborative NashvilleHealth to address health disparities and inequities in Nashville, with a goal to substantially improve the health of every Nashvillian. Working with our academic partners at Vanderbilt University and Meharry Medical College, our partners at the Robert Wood Johnson Foundation, and stakeholders throughout the broader Nashville community, we successfully engaged in a number of evidence-based health-promoting activities, but it quickly became apparent that we lacked baseline health and equity data, especially when it came to the LGBTQ+ community. Few if any Southern cities at the time had accurate LGBTQ+ public health survey data. In response, we conducted the “Nashville Community Health + Well-being Survey,” our first countywide health assessment in nearly 20 years. As NashvilleHealth chairman and lead architect of the survey, I included specific survey questions to help us better define sexual orientation and gender identity equity issues, which in turn for the first time brought to light and quantified substantial lesbian, gay, bisexual, and transgender health disparities in every zip code in Nashville and Davidson County.

What we found was dramatic. Our lesbian, gay, bisexual and transgender residents disproportionately reported unmet care needs and reported twice the number of poor mental health days each month compared to heterosexual Nashvillians. They were nearly twice as likely to report having been diagnosed with depression, with 22% saying they rarely or never received needed social support. They also were more likely to be uninsured (30%), at a rate four times higher than heterosexual Nashvillians (7.5%). And likely in part as a result, were less likely to have visited a doctor for a routine checkup in the past year.

Publication and sharing of information

Data and information alone are limited in value unless shared with others. One venue is periodicals. In an article I wrote for Forbes last year, I said: “And the egregious inequities in our city’s health and well-being extend beyond race and ethnicity. Our lesbian, gay, bisexual, and transgender (LGBT) population … were more likely to be uninsured, report unmet medical care needs because of cost, and exhibit worse mental health outcomes.”

Another venue in which to raise awareness is the national academic community though peer-reviewed articles. Thus, in January 2021 my team at NashvilleHealth and investigators from Vanderbilt University published in the Southern Medical Journal the research article entitled, “Health Disparities among Lesbian, Gay, Bisexual, and Transgender (LGBT) Adults in Nashville, Tennessee.” The authors concluded: “To achieve health equity for LGBT individuals at the municipal level, Nashville and Tennessee should consider multifaceted approaches to expanding health insurance coverage and nondiscrimination protections and address mental health and human immunodeficiency virus risks among vulnerable populations.” The authors also underscored that the study “provides the community with baseline data for monitoring LGBT health disparities and serves as a model for other southern cities.”

Continued national discussion

My journey includes a personal commitment to help inform the attitudes of others using newer media across states throughout the country. An example is the podcast A Second Opinion: Rethinking American Health with Senator Bill Frist, where I featured Dr. Jesse Ehrenfeld, director of the “Advancing a Healthier Wisconsin Endowment” at the Medical College of Wisconsin, a champion for LGBTQ+ health, and the now-incoming chair of the American Medical Association, for a lengthy discussion on a range of LGBTQ+ issues. He shared: “On the access side, LGBT people have less access to healthcare, less likely to have health insurance, less likely to fill prescriptions, more likely to use the emergency room for care, more likely to delay care, and unfortunately continue to often be refused healthcare services or even be harassed by providers.” He further explained how the “insurance gap is a symptom of a larger problem. The lack of healthcare coverage for LGBTQ people is really driven by economic disparities, job discrimination and the lack of opportunity.”

So, my own journey continues. I want to listen more. I want to know more. I want to be more open. I regret having started in the wrong place, but I hope to end in the right one.

In this moment where it seems we as Americans are too divided and at each other’s throats over deep-seated cultural beliefs, we as a society, too, can do better. We can grow and continue to heal our nation, together across this great country. The once widely-supported Defense of Marriage Act of 1996 was ruled unconstitutional by the Supreme Court in 2015, with the majority of Americans in agreement, a true sea-change in sentiment. Over two decades, we have come together to identify an injustice, change hearts and minds (mine, for sure), and progressively right a wrong in the name of respect, love and equity. As Martin Luther King, Jr. famously said, “The line of progress is never straight. … Often it feels as though you were moving backwards, and you lose sight of your goal: but in fact you are moving ahead.”