Public Health Madison & Dane County (PHMDC) is a City/County health department with a staff of more than 140 people, serving over 500,000 residents in approximately 60 cities, villages, and towns across Dane County, the largest city of which is Madison. PHMDC is located in southcentral Wisconsin, and is the second-most populous county in Wisconsin (second to Milwaukee County). The racial makeup of Dane County is approximately 85% White, 5% Black or African American, 0.4% Native American, 5% Asian, and 2.5% from two or more races. 6% of the population is Hispanic or Latinx (Dane County Wisconsin, 2019). Across the state of Wisconsin, an estimated 3% of residents identify as LGBTQ+, though sources suggest that this proportion is much greater in Dane County, and the Madison metropolitan area is often cited as one of the most LGBTQ+ friendly cities in the nation (Madison makes Top 10 list of most-friendly LGBTQ cities. Wisconsin Gazette, 2011).

PHMDC works to enhance, protect, and promote the health of the environment and well-being of all people. Promoting systems of Health and Racial Equity (HRE) is both a core value and a strategic priority for PHMDC. Our collective vision for health equity is that all people in Dane County will have fair and just opportunities to be healthy. This cannot happen without confronting and addressing the obstacles that make it more difficult for certain groups and individuals to achieve maximum health because of characteristics like race, class, gender, sexual orientation, and/or ability.

The public health problem identified for this NACCHO application relates to the health systems, policies, and structures that disproportionately impact the health of our LGBTQ+ population. In fact, national data suggests that people who identify as LGBTQ+ continue to experience worse physical and mental health outcomes than their heterosexual or cisgender peers (Harcourt, J. 2006). In the fall of 2016, the National Institutes of Health (NIH) announced the formal designation of sexual and gender minorities (SGM) as a health disparity population for NIH research (Sexual and Gender Minorities Formally Designated as a Health Disparity Population for Research Purposes. Perez-Stable, 2016). Data shows that economic and social conditions, along with policies and laws, profoundly shape health outcomes (World Health Organization, Social Determinants of Health, 2016) and people who identify as LGBTQ+ experience worse health in part because of these conditions and structural impediments (Centers for Disease Control and Prevention, Social Determinants of Health, 2015). In Dane County, local data mirrors statewide and national trends and shows that LGBTQ+ inequities persist across the life course. LGBTQ+ youth are more likely to try tobacco, cocaine, inhalants, heroin, report feeling depressed, and feel unsafe in school (Healthiest Wisconsin 2020 Baseline and Health Disparities Report: Lesbian, Gay, Bisexual, and Transgender Populations, January 2014). LGBTQ+ adults are less likely to have health insurance or regularly visit a dentist (Jennings, L., Barcelos, C., McWilliams, C. & Malecki, K. (2019). Inequalities in lesbian, gay, bisexual, and transgender (LGBT) health and health care access and utilization in Wisconsin. Preventive Medicine Reports). LGBTQ+ older adults commonly feel isolated and face higher rates of housing and employment discrimination (Cahill S., South K., Spade J. (2009). Outing age: Public policy issues affecting gay, lesbian, bisexual and transgender elders. Washington: National Gay and Lesbian Task Force). Furthermore, few data systems or health surveys collect comprehensive LGBTQ+ health related data, rendering targeted interventions difficult to plan and implement.

The goals of our efforts to tackle these disparities are threefold. First, to increase transgender health access at PHMDC’s Sexual and Reproductive Health Clinic. Second, to institutionalize LGBTQ+ health equity into The City of Madison policies and training schedule. Third, to develop a local index of LGBTQ+ health equity indicators for Dane County health care systems to assess their own policies, practices, and environments as they relate to LGBTQ+ health care. A future goal is to provide technical assistance to health care systems in order to support them in changing their existing structures to be more inclusive and welcoming for all.

This work has been in process for the last three years. PHMDC’s LGBTQ+ health equity work began with a county-wide LGBTQ+ community needs assessment, which resulted in the creation of a data profile, replete with numerous recommendations to improve LGBTQ+ health outcomes across Dane County. The recommendations led to the inception of the projects stated above. PHMDC partnered with a transgender health system advocate to design internal trainings for our Sexual & Reproductive Health (SRH) clinic staff, and required attendance for all employees. We also worked with members of our LGBTQ+ community to develop and facilitate LGBTQ+ Health Equity trainings for city/county staff, and are currently working towards designing and implementing city-wide policies for transgender employees. We are currently in the process of implementing a health care assessment strategy, which will lay the groundwork for the local LGBTQ+ health equity index to be applied in 2020.

While the profile has more recommendations that have not been initiated, we are proud of the projects we have successfully implemented and their results. Writing the initial data profile was instrumental in our project’s successes. Using data to drive recommendations, we were able to make impactful change to systems that are currently failing Dane County’s LGBTQ+ population. Furthermore, we gained institutional buy-in from PHMDC’s leadership team as well as the City of Madison Human Resources Department. PHMDC’s website can be found here: https://publichealthmdc.com/.