Health care access isn't equal.

By Claire Gillespie
June 12, 2020
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We all rely on health care services at some point in our lives, and many of us take them for granted. But not everybody has the same access to medical advice and treatment. As a result, certain populations suffer poorer health outcomes.

These are known as health disparities—defined by the Centers for Disease Control and Prevention (CDC) as “preventable differences in the burden of disease, injury, violence, or opportunities to reach your best health that are experienced by socially disadvantaged populations.” 

In 2016, the LGBTQ+ community was identified as a “health disparity population” by the National Institute on Minority Health and Health Disparities, partly because individuals who identify as part of this group have less access to health care. LGBTQ+ people encompass all races, ethnicities, religions, and social classes. But when an LGBTQ+ person belongs to another marginalized group, such as being a person of color, it becomes even more difficult to find accessible, unprejudiced care. “These health disparities tend to amplify due to the intersectionality of oppression,” Kristen Martinez, an LGBTQ+ affirmative counselor at Pacific NorthWell in Seattle, tells Health. 

A 2017 nationally representative survey of LGBTQ+ people conducted by the Center for American Progress bears this out. The survey found that nearly one in 10 LGBTQ+ individuals reported that a health care professional refused to see them in the prior year because of their actual or perceived sexual orientation. Nearly three in 10 transgender people reported that providers would not see them because of their gender identity. 

Laura Durso, PhD, chief learning officer and executive director of Washington, DC’s Whitman-Walker Institute, a nonprofit committed to advancing social justice and equality through health, tells Health that various factors may contribute to LGBTQ+ people not having equal access to basic medical services, such as mammograms or screening tests. “Lack of access to health insurance and quality coverage, greater vulnerability to poverty, and unwelcoming and discriminatory social environments all play a role,”  she says.

“Those discriminatory environments cause LGBTQ people to experience minority stress—the stress associated with experiencing both institutional and interpersonal stigmas because of one's sexual orientation or gender identity—which has been shown to be associated with negative health outcomes.”

These are the six main health disparities faced by the LGBTQ+ community. 

Higher rates of sexually transmitted infections

In the United States, gay, bisexual, and other men who have sex with men (MSM) are the population most affected by human immunodeficiency virus (HIV). According to the CDC, adolescent and adult gay and bisexual men made up 69% of the 37,832 new HIV diagnoses in the US in 2018. The CDC also states that anal sex is the riskiest type of sex for getting or transmitting HIV, and most gay and bisexual men get HIV from having anal sex without protection—such as using a condom or taking medicine to prevent or treat HIV.

Gay and bisexual men are also at a higher risk for other sexually transmitted infections (STIs), such as chlamydia, syphilis, and gonorrhea, which can all greatly increase the chance of getting or transmitting HIV. 

Figures show that LGBTQ+ people are more likely to have human papillomavirus (HPV) infection. According to a study published in The Journal of Infectious Diseases in 2017, gay, bisexual, and MSM are about 20 times as likely as heterosexual men to develop anal cancer, of which HPV is a recognized cause. HPV is the primary cause of cervical cancer in women, but it’s also a risk factor for ano-genital cancers. In addition, it's linked to head and neck malignancies, due to transmission of the virus via oral sex

More substance use and abuse

Studies are conflicting, but some research suggests that substance use and abuse is more prevalent in the LGBTQ+ community than in non-LGBTQ+ groups. 

According to a CDC report published in 2018 (based on data from the 2016 National Health Interview Survey (NHIS), 20.5% of lesbian, gay, and bisexual adults smoked, compared to 15.3% of heterosexual adults. Smoking increases the risk for coronary heart disease, stroke and lung cancer, and a host of other health conditions. 

Research published in LGBT Health in 2019 highlights high rates of substance abuse disorders in the LGBTQ+ community. People who identified as lesbian or gay were more than twice as likely as people who identified as heterosexual to have a "severe" alcohol or tobacco use disorder, while people who identified as bisexual were three times as likely to have this kind of substance use disorder. 

Boston’s Fenway Institute is a community organization dedicated to advancing health and well-being for sexual and gender minorities and those affected by HIV. Their 2016 report, Improving the Health Care of Lesbian, Gay, Bisexual and Transgender People: Understanding and Eliminating Health Disparities, says that other drug abuse may also be more common among LGBTQ+ as opposed to heterosexual men and women. One 2017 study published in the Journal of School Health found that transgender students were about 2.5 times more likely to use drugs like methamphetamines and cocaine than their cisgender peers.

Higher rates of mental health conditions

Many studies have suggested higher rates of mental illness in the LGBTQ+ community. A large cohort study published in Pediatrics in 2018 found that transgender and/or gender nonconforming (TGNC) youth were several times more likely to have attention deficit disorders and depressive disorders than non-TGNC youth. And a meta-analysis of UK population health surveys, published in BMC Psychiatry in 2016, found that LQBTQ+ people are more than twice as likely as heterosexual men and women to have a mental health disorder in their lifetime. 

“Queer and trans folks tend to be more prone to anxiety, depression, suicidality, eating disorders, and substance dependence, which are all the effects of systemic oppression,” says Martinez.

Health care disparities can also lead to mental health issues in LGBTQ+ people, Martinez adds. “Remember that queer and trans folks have an understandable fear and mistrust of the health care system,” she says. For starters, the DSM (Diagnostic and Statistical Manual of Mental Disorders, the so-called “psychiatric Bible") listed “homosexuality" as a disorder until 1973. And trans and non-binary folks still need a diagnosis of "gender dysphoria" (previously known as "gender identity disorder") so they can access life-saving and life-affirming treatment, like hormone therapy or feminizing or masculinizing surgery.

“If you are a trans man who can't find a provider to give you a pap smear due to systemic oppression, of course that will be affecting your mental health and well being, and how you see yourself and value yourself," says Martinez. "If you have to teach your health care providers about the lived experience of being trans and/or queer, that is a burden that should not be on your shoulders but often is, on top of accessing care, having resources to pay for care, and more.”

Higher odds of obesity and eating disorders

A study published in the International Journal of Environmental Research and Public Health in 2019 looked at data from 2014–2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys and found that bisexual and lesbian women were more likely to be overweight or obese than women who identify as heterosexual. However, gay men had significantly lower odds of being obese as opposed to straight men (there was no significant difference when it came to bisexual men). In addition, eating disorders and body image disorders may be more common among gay and bisexual men than heterosexual men, per a study published in the Archives of Pediatrics and Adolescent Medicine

“In comparison to their straight peers, LGBTQ+ individuals experience unique stressors such as bullying, harassment, fear of rejection, internalized homophobia, body image distress, barriers to accessing medical and mental health treatment, and violence,” Sydney Brodeur McDonald, PhD, senior director for clinical services at Veritas Collaborative, a national healthcare system for the treatment of children, teens, and adults with eating disorders, tells Health. “These stressors place them in a higher risk category for the development of eating disorders and other mental health issues. 

Higher rates of breast and cervical cancers

Although there's not a lot of data on cancer rates within the LGBTQ+ community, the National LGBT Cancer Network says LGBT communities are “disproportionately affected by cancer.” 

A 2000 study analysis of data from more than 93,000 women between ages 59-70 published in the Archives of Family Medicine suggests that lesbian and bisexual women have higher rates of breast and cervical cancer compared to heterosexual women. However, it’s not known whether this is due to lower rates of screening, nulliparity (the condition of not having been pregnant), or other factors known to raise the risk of these cancers, such as alcohol use and obesity. 

According to a comparative study of data on more than 800,000 men and women published in the American Journal of Public Health in 2010, women in same-sex relationships were less likely to have had a recent mammogram or Pap test than heterosexual women.

In 2013, a systematic review of all US and UK evidence on whether there is a higher rate of breast cancer in lesbian and bisexual women concluded that the only realistic way to answer this question is to collect sexual orientation within routine statistics, including cancer registry data, or from large cohort studies. 

Greater risk of heart disease 

A study published in the journal Circulation in 2018 found that lesbian, gay, and bisexual adults have a higher risk of heart disease and other cardiac problems than heterosexual adults. Researchers at Miami’s Baptist Health South Florida Clinic focused on seven areas of controllable heart health and found that people in sexual minority groups were more likely to be smokers and have poorly controlled blood sugar, which both contribute to heart disease. 

How to help LGBTQ+ people get equal health access

If an LGBTQ+ person has had a bad experience with a medical professional, they might choose to stay away from health care settings. The 2017 Center for American Progress survey showed that once people experience discrimination in some form, they are more likely to avoid doctor's offices. Among LGBTQ+ people who had experienced discrimination in the year prior to the survey, more than 18% reported avoiding doctor's offices out of fear of discrimination.   

Whether you’ve experienced discrimination in a health care setting or not—or you have LGBTQ+ friends or family members who've encountered bias—your fear around care is valid, says Stephen Abbott, MD, staff physician at Whitman-Walker Health. “My advice is to seek out LGBTQ+ health resources and directories,” Dr. Abbott tells Health.GLMA: Health Professionals Advancing LGBTQ+ Equality (previously known as the Gay & Lesbian Medical Association) maintains an LGBTQ+ inclusive provider directory.” 

You can also search for organizations that advocate for and provide direct health services to LGBTQ+ populations in your state, such as Maine’s Health Equity Alliance and the UCSF Center for LGBT Health & Equity in California. The Trevor Project is a non-profit providing crisis intervention and suicide prevention services to LGBTQA+ youth (under 25s), while Trans Lifeline is a hotline run by and for trans people. And the LGBT National Help Center provides free, confidential peer support and information on local resources to help with anything from coming out issues to sexual abuse. 

Due to COVID-19, with many health care services still not fully open, telehealth access could be an option, suggests Dr. Abbott. “When there is access to technology and the internet, telehealth can create a unique opportunity to connect LGBTQ+ communities, and other communities with limited access to care, from their homes or where they stay.” 

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