Additional barriers to quality health care include internalized fears, external conditions, and institutional traditions and practices.

Internalized Barriers
Oddly enough, we may have grown up learning to hate those who are like us and develop a hatred of ourselves because of our gender identity or sexual orientation. But we know, at some level, that we are what we have been taught to hate. It's not unlike the reaction of many minorities who have been raised in the predominant culture. This is not something your provider can 'heal', but it is something you can become aware of and overcome. (For help with this, contact your coach.)

External Barriers
If our expectation is that we will to be treated differently by a practitioner or their support staff, we may feel anxiety and avoid seeking medical or mental health care. But we are just as entitled to quality health care as everyone else and since our medical and mental health are essential parts of our lives, we should expect treatment that is no different from that accorded to anyone else. If you sense, in any way, that the treatment you receive is not equivalent to that given to others, you should make it clear to your practitioner or provider that you expect nothing less. They may simply be uncomfortable with LGBT issues. More than likely they have not been taught in medical school how to deal with these issues and so it becomes incumbent upon us to guide them. Bring them material to read or refer them to the professional version of this course.

Institutional Barriers
Society's institutions (i.e.: churches, government, clinics and hospitals, the courts) have long-established practices that inhibit open and honest communication. For example, in a medical setting, practitioners may not allow a partner or significant other into into an exam room or make the partner or significant other feel uncomfortable when present. Likewise, barriers are created by HMO's that exclude gay and lesbian partners from health insurance benefits. The same is true of social agencies that deter LGBT's from legally adopting children or receiving reproductive technology. If this is the case with your church, clinic, hospital, or social agency, they need to be educated as well. Here are some things you can do to make that happen:

• Identify appropriate training programs and have them contact your provider;

• Refer the provider to these programs;

• Ask the provider to change intake and assessment forms that routinely say "husband" and "wife;"

• Explain to the provider that stereotypical assumptions about LGBT people are wrong and result in some LGBT people being "invisible." (There are LGBT people of color, LGBT poor, elderly LGBT's, and those living with disabilities, or for whom religion or parents make it difficult to come out to their medical professional);

• Promote training in LGBT couple issues; identify therapists who specifically work with lesbian or gay male couples;

• Provide your therapist with information on bisexual and transgendered people;

• Encourage your employer to include health insurance programs that allow coverage for LGBT folk or their families;

• Support the work of GLSEN and other organizations that are working to change attitudes toward LGBT youth who are often silenced or told that they are too young to know if they are gay;

• Encourage your physician to routinely screen EVERYONE for STD's (They often make the assumption that because someone is married he or she does not engage in same-sex or non-monogamous sex.);

• Provide information to physicians who make decisions about alternative reproductive methods, surrogacy, or adoption, or lawyers who provide advice on the legal implications of family-building within a homophobic culture;