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Abstract

In the United States, lesbian, gay, and bisexual persons (LGBPs) of color may experience great difficulty obtaining high quality health care and/or health-related interventions. Issues surrounding access to health care may explain the disproportionate numbers of LGB ethnic minorities experiencing poor health outcomes relative to nonminority and non-LGB persons. This chapter presents research that may help to explain why African American, Asian and Pacific Islander (API), and Latino LGBPs have a lack of access to quality health care and a higher prevalence of poor health outcomes than other populations. The chapter also explores the ways in which access to health care can be improved for minority LGBPs and presents suggestions for institutional-, community-, and policy-level interventions.
25
Improving Access to Health Care
Among African-American,
Asian and Pacific Islander, and
Latino Lesbian, Gay, and
Bisexual Populations
Patrick A. Wilson and Hirokazu Yoshikawa
1 Introduction
In the United States, lesbian, gay, and bisexual persons (LGBPs) of color
may experience great difficulty obtaining high quality health care
and/or health-related interventions. Issues surrounding access to
health care may explain the disproportionate numbers of LGB ethnic
minorities experiencing poor health outcomes relative to nonminority
and non-LGB persons. This chapter presents research that may help to
explain why African American, Asian and Pacific Islander (API), and
Latino LGBPs have a lack of access to quality health care and a higher
prevalence of poor health outcomes than other populations. The
chapter also explores the ways in which access to health care can be
improved for minority LGBPs and presents suggestions for institu-
tional-, community-, and policy-level interventions.
2 Importance of Understanding Health Disparities
Among Ethnic Minority LGB Persons
Ethnic minority LGBPs are at risk for a variety of poor physical health
outcomes. Perhaps the most studied of these outcomes are sexuality
transmitted infections (STIs), such as human immunodeficiency virus
(HIV) infection. HIV has had a tremendous impact on the LGB com-
munity, as gay men constituted most of the HIV and acquired immun-
odeficiency syndrome (AIDS) cases during the 1980s and early 1990s.
However, as the epidemic has grown and changed, ethnic minority
men who have sex with men (MSM), notably those who are African
American and Latino, represent the highest proportion of new AIDS
cases in the United States (CDC, 2002). MSM also show high rates of
other STIs, including hepatitis B, gonorrhea, Chlamydia, and other bac-
terial infections (Council on Scientific Affairs, 1996). Inclusive of HIV,
ethnic minority MSM have higher rates of most STIs than White MSM
(CDC, 2003). Lesbians who are ethnic minorities also face great health
challenges relative to other groups. Although lesbian women have a
lower incidence of STIs than heterosexual women, some research sug-
gests that these women are at heightened risk for certain cancers
including breast, ovarian, and endometrial malignancies (Council of
Scientific Affairs, 1996). This greater risk may stem from lesbians’
higher likelihood of nulliparity (i.e., to have never given birth to a
child) than heterosexual women. Ethnic minority lesbians have a
greater chance of experiencing these poor health outcomes and not
receiving treatment for them because of their greater likelihood of not
having health insurance and not receiving preventive care (Dean et al.,
2000; Mays et al., 2003).
Mental health problems also occur with frequency among LGB
ethnic minorities. LGBPs are more likely than heterosexuals to ex-
perience major depression and anxiety disorders (Gilman et al., 2001;
Cochran et al., 2003). Ethnic minority LGBPs may be more likely to
experience mental health problems than other populations. For
example, when studying depressive distress among gay and lesbian
African Americans, Cochran and Mays (1994) found higher rates of
depression (as measured by the CES-D) among African-Americans, rel-
ative to White gay men and non-LGB African Americans. Similarly,
levels of depressive symptoms have been observed in samples of API
gay men (Yoshikawa et al., 2004) and Latino gay men (Díaz et al., 2004)
that are higher than those obtained in comparable general-population
studies of these ethnic groups. Studies specifically examining depres-
sion and mental health among lesbians of color are scarce and much
needed for this population. Related research suggests that these
women may be more likely to experience mental health issues, as
many experience stigma based on their ethnicity, sexuality, and gender
(Phillip, 1993; Greene, 1997).
Many ethnic minority LGBPs also contend with substance use and
addiction and the health problems that may result from substance-
using behaviors. Studies indicate that gays and lesbians are more likely
to abuse drugs and alcohol than heterosexuals (Council of Scientific
Affairs, 1996; Cochran, 2003). Medical professionals report that the
prevalence of substance use among LGBP ranges between 28% and
35%, compared to 10% to 12% for heterosexual persons (Cabaj, 1992).
Though studies are scant, ethnic minority LGBPs may be more likely
to engage in substance use and/or abuse in an effort to reduce stress
stemming from stigma and to alleviate the psychological discomfort of
engaging in same-sex sexual behavior (Icard & Traunstein, 1987;
Semple et al., 2002; Wilson, 2005).
Data collected over the past several years have consistently demon-
strated significant health disparities between minority and nonminor-
ity groups in the United States. As a result, research aiming to explain
608 P.A. Wilson and H. Yoshikawa
disparities in health and access to health care has been called for in
both community-based organizations and government organizations.
Notably, in 2000 Congress passed the Minority Health and Health Dis-
parities Research and Education Act
1
in response to President Clinton’s
Healthy People 2010 initiative, which aimed to eliminate health dis-
parities among Americans by 2010. The National Center on Minority
Health and Health Disparities was created through the Act, and hun-
dreds of millions of dollars were earmarked for research and inter-
vention aimed at reducing health disparities. The Health Disparities
Act, one of the most notable pieces of health legislation over the past
decade, gave visibility and much needed funding to interventions
created to tackle the health disparities problem in the United States.
However, the Act and the five Titles that comprise it focus on health
disparities between persons of different racial/ethnic groups and
neglect to place attention on the special health needs of LGBPs. In an
effort to shed light on the healthcare needs and issues of LGBT people,
the Gay and Lesbian Medical Association (GLMA) published an
exhaustive report on the state of LGBT health in the United States
shortly after passage of the Health Disparities Act (GLMA, 2001). The
document served to fill in the gaps in federal initiatives on health dis-
parities and was a supplement to the President’s original Healthy
People 2010 mandate. Although this work has been useful to highlight
the importance of understanding and eliminating health disparities
across more than simply race categories in the United States, little work
has focused specifically on the health care needs of ethnic minority
LGBPs. Most attention to health disparities has been placed either on
the needs of ethnic minorities or LGBPs, but not the needs of persons
who belong to both groups. Nonetheless, ethnic minority LGBPs may
experience a compounded effect of their ethnic and sexual minority sta-
tuses with regard to their health, and these effects may result in poorer
health outcomes when compared to those of White LGB populations
or the U.S. population as a whole.
3 Intersection of Ethnicity, Sexual Orientation,
and Immigration Experiences: Their Impact on Health
and Healthcare Access
Why are ethnic minority LGBPs at heightened risk for poor health out-
comes compared to other populations? Why are ethnic minority LGBPs
less likely than White LGBPs to receive high quality health care? These
questions must be answered to effectively design and implement inter-
ventions that promote health and access to health care among LGB
ethnic minorities. The relevant research suggests three major factors
that may play a role: (1) the negative impact of discrimination on health
and risk behavior; (2) racism and homophobia in health care and
25 Improving Access to Health Care 609
1
The Minority Health and Health Disparities Research and Education Act of
2000, S. 1880, 106th Congress, 2nd Session.
health-related research settings, and (3) immigration experiences and
their effects on health care.
3.1 Negative Impact of Discrimination on Health and
Risk Behavior
Logically, membership in socially constructed demographic groups
defined by race/ethnicity and sexual orientation should not cause poor
health. Thus, the relation between demographic characteristics and
poor health outcomes must be mediated by factors associated with
being a person who belongs to an ethnic and/or sexual minority. One
such mediating factor important to consider is discrimination. Dis-
crimination, in all of its forms (i.e., structural, institutional, interper-
sonal), has an adverse impact on the health of those who experience it
(Clark et al., 1999; Krieger, 1999). Several researchers have noted that
the psychological and physiologic stress that stems from the experience
of discrimination is related to acute and chronic health problems
among those who are discriminated against. For example, Williams
et al. (1999) found that African Americans who reported recurring
experiences of racism were more likely to have chronic health problems
(e.g., cardiovascular disease, hypertension) than those who did not
have such experiences. Similarly, research has suggested that the strain
associated with persistent racism the ethnic minorities experience may
be linked to stress-related diseases such as high blood pressure (Krieger
& Sidney, 1996) and heart disease (Jiang et al.), as well as psychologi-
cal disorders such as depression (Rumbaut, 1994), psychological dis-
tress (Williams, 2000), and low self-esteem (Broman, 1997).
Discrimination also plays a role in the adverse health outcomes of
LGBP, regardless of their ethnicity. Notably, studies have suggested
that the chronic experience of stigma linked to sexual orientation and
the stress that ensues from such stigmatization is linked to greater risk
behavior and poor mental health in LGBP. For example, Meyer (1995)
found that gay men were more likely to report psychological distress
(including distress linked to demoralization, guilt, suicide, and AIDS
traumatic stress response) when they reported experiencing antigay
violence and/or discrimination. In a related study, Meyer and Dean
(1995) found that gay men who engaged in high levels of sexual risk
behavior were more likely to have high levels of internalized homo-
phobia, which the authors posited may result from antigay attitudes
and being stigmatized by heterosexuals.
The combined effects of being stigmatized as both a sexual minority
and an ethnic minority may have especially adverse health conse-
quences. Studies of ethnic minority gay men have demonstrated a link
between discrimination and negative health outcomes, including risky
sexual behavior and poor mental health. In one study, Díaz and Ayala
(2001) found that experiences of social discrimination (rooted in racism
and/or homophobia) were strong predictors of both psychological dis-
tress and sexual risk behavior in their study of Latino gay men. Simi-
larly, a study examining the impact of discrimination on HIV risk
among API gay men found that experiences of racism were linked to
610 P.A. Wilson and H. Yoshikawa
depression, and experiences of antiimmigrant discrimination were
related to higher rates of unprotected sex with casual partners
(Yoshikawa et al., 2004). The experience of being in a minority within
an already disenfranchised group (as is the case with ethnic minority
LGBPs) may create difficulty engaging in healthy behaviors and
responding to discrimination, notably that which stems from other
minority group members. For example, Wilson and Yoshikawa (2004)
found that API gay men who experienced discrimination based in
stereotypes about Asian gay men as passive, exotic, and/or feminine
were more likely to engage in sexual risk behavior than those without
such experiences. Participants noted that this form of discrimination
was rooted within the White gay community and emphasized the dual
minority status of API gay men. Research examining the impact of dis-
crimination on the health of LGBPs is still in its formative stage, and
there is a paucity of studies on other ethnic and sexual minority groups,
notably ethnic minority lesbians or bisexuals. Nonetheless, the avail-
able research suggests that ethnic minority LGBPs’ experiences of
discrimination are consistently associated with poorer health and
health-related behaviors and that they likely contribute to disparities
in health.
3.2 Racism and Homophobia in Health Care and
Health-Related Research Settings
Discrimination affects not only the health of ethnic minority LGBPs but
also their health care experiences. Indeed, U.S. health care and research
settings have a long history of discriminatory practices with regard to
ethnic and sexual minorities. These practices have created a legacy of
distrust and nonutilization of the health care system among ethnic
minorities as well as LGBPs. The Tuskegee syphilis experiments may
represent the most atrocious form of health- and research-based racism
in the United States, with the most lasting effects on African Americans
and members of other ethnic groups. During the experiments, which
lasted 40 years, hundreds of African American men with syphilis went
untreated by medical professionals, who were interested in studying
the progression of the disease. Men were deceived by the physicians in
the study, who told them they were being treated for “bad blood” and
offered several incentives for study participation (for a complete
description on the experiments and their impacts, see Jones, 1993).
While current medical research is conducted with relatively stringent
standards for the protection of human subjects, discriminatory prac-
tices in health-related research have affected the way ethnic minorities
view and use the healthcare system. Notably, researchers have posited
that the deception involved in the Tuskegee experiments may be linked
to the belief (predominantly held by ethnic minorities) that HIV/AIDS
is a government-made form of genocide (Thomas & Quinn, 1991;
Gamble, 1993).
Though such conspiracy theories were much more popular during
the 1980s and early 1990s, the core belief that the U.S. healthcare
system cannot be trusted persists among many ethnic minorities and
25 Improving Access to Health Care 611
is linked to their higher rates of poor health outcomes. For example,
Dalton (1989) noted that the African-American community’s mistrust
of early HIV/AIDS prevention initiatives led to the resistance in
accepting AIDS as a significant health issue within the community and
delayed the enactment of prevention efforts. Indeed, research suggests
that ethnic minority LGBPs are distrustful of medical and mental health
professionals and perceive the health care system to be disinterested in
minority health needs (Dowd, 1994; Klonoff & Landrine, 1997; Siegel
& Raveis, 1997). Distrust of healthcare professionals and the healthcare
system is rooted in a legacy of racism in the healthcare system: Ethnic
minorities frequently report personal experiences of neglect, misun-
derstanding, and a lack of cultural competence when accessing health
care. For example, Blanchard and Lurie (2004) found that 14% of
African Americans, 19% of Latinos, and 20% of APIs reported being
looked down upon or treated with disrespect during their interactions
with health providers, compared to 9% of Whites. Participants who
reported being treated in a disrespectful manner were more likely to
report not following their doctor’s advice and putting off necessary
medical care. Correspondingly, a study of satisfaction with mental
health services among people with major mental illness revealed that
LGBPs were more likely to report dissatisfaction with their mental
health care than non-LGBPs (Avery et al., 2001). However, African
American and Latino LGBPs reported dissatisfaction with mental
health services more frequently than nonminority LGB participants.
Such experiences among LGBP of color lead to nonutilization of the
healthcare system among this population: They are likely to believe
that healthcare professionals will be insensitive to their mental and
physical health needs as both ethnic and sexual minorities (Parés-Avila
& Montano-López, 1994; Greene, 1997). A participant’s quote in Male-
branche and colleagues’ (2004) study of perceptions of health care
among African American MSM highlights the difficulty of achieving
quality care as an LGBP of color.
As being a young black male, if [I] would come and say something’s wrong
with me, they [medical providers] would say, ‘oh, look at this, you know, they
probably just hip-hoppin’ and screwin’ down, and you know, smokin’ the
blunts, and then he gonna come in here talkin’ about he sick.’ So it’s like I’m
stereotyped already. And now, if you say you’re gay, everybody can get the
picture of the feminine, gay brother. So I guess it can come to sexuality because
they [medical professionals] feel, ‘oh, he must have been [sexually promiscu-
ous] already’. [pp. 101–102]
As this quote suggests, homophobia is a major barrier to accessing
quality health care among ethnic minority LGBPs. Homophobia in
health care settings is tied to a lack of training of health professionals
and a lack of understanding of the health needs of people who are
lesbian, gay, or bisexual. In a literature review of studies examining the
utilization of healthcare programs among gay men and lesbians,
Maccio and Douceck (2002) observed that LGBPs frequently reported
negative attitudes among healthcare workers and a lack of prepared-
612 P.A. Wilson and H. Yoshikawa
ness in handling health issues related to sexual orientation. The
researchers examined health care programs in mental health counsel-
ing, addiction treatment, pediatric care, and gynecologic care. A survey
conducted of gay and lesbian physicians in the United States revealed
that whereas 98% of those surveyed believed it was important for
patients to disclose their sexual orientation to healthcare providers,
64% also believed that by disclosing homosexual behavior patients
risked receiving substandard care (Shatz & O’Hanlan, 1994). Research
has shown that physicians frequently assume that all their LGB patients
are heterosexual, which contributes to anxiety surrounding the disclo-
sure of sexual orientation and perceptions that disclosure would have
negative consequences on their health care (Barbara et al., 2001; Eliason
& Schope, 2001). The available research appears to confirm negative
health care experiences among LGB persons. Stevens (1998), when
detailing the health care experiences of lesbians, found that of the 332
health care interactions reported by the women, less than one-fourth
were evaluated positively. For example, one of the study participants
stated:
White male doctors make it their job to see to it that Black women do not
have anymore babies...Whenever I went in [to a doctor’s office] they would
never let up when I said no, I don’t need birth control. So sometimes I would
come out as a lesbian, just to get them to move on to other things. The doctors
would fumble around and say something like, “Oh...I’m sorry.” It was so
awkward ...I always felt harassed because I am Black and because I am a
lesbian. [p. 84]
Most of the women in Stevens’ sample reported negative experiences
due to prejudice linked to sexual orientation, race, and socioeconomic
status, and almost half of the women stopped seeing their healthcare
providers as a result of negative experiences.
Stigma associated with HIV/AIDS in health care settings may also
play a role in the discrimination experienced by LGBPs. Many health
care professionals, notably those with limited experience working with
LGB individuals, associate AIDS is homosexuality. The idea that
HIV/AIDS is a gay disease—it was labeled gay-related immune defi-
ciency (GRID) before being identified as HIV—has persisted over
time (Caldwell, 1994). Although today most health professionals
acknowledge HIV/AIDS as a disease affecting people from all back-
grounds, many continue to stigmatize certain at-risk subgroups. Some
LGBPs, notably gay men, assume that once they divulge their sexual
orientation health care professionals automatically suspect that
they have HIV/AIDS or will at some point contract the virus (Male-
branche et al., 2004). It is also important to note the lack of discussions
about HIV and its prevention and treatment that occur between
patients and their primary care physicians (Gerbert et al., 1991; Council
on Scientific Affairs, 1996). A lack of discussion about HIV may affect
LGBPs of color more than White LGBPs, given that LGBPs of color are
less likely to come out to their physician or disclose certain sexual
behaviors.
25 Improving Access to Health Care 613
As noted, patients’ nondisclosure of their sexual orientation to their
healthcare provider may be linked to their poor health. This has
serious implications for ethnic minority LGBPs, who may experience
more difficulty letting others know their sexual orientation than LGBPs
who are not ethnic minorities. Research has shown that a variety of
social and cultural factors are linked to discomfort about disclosing
sexual orientation among ethnic minorities. These factors include cul-
tural norms of sexual silence (Dowd, 1994; Gomez & Marín, 1996; Díaz,
1998; Chng et al., 2003), prominent religious beliefs (Woodyard et al.,
2000), and familial obligations regarding marriage and procreation
(Morales, 1990). Actual and expected experiences of homophobia
and/or AIDS-related stigma in healthcare settings further promote
nondisclosure of sexual orientation and internalized homophobia.
Indeed, research has shown that LGBPs who have disclosed their
sexual orientation to their health care providers are more likely to be
White than African American or Latino (Klitzman & Greenberg, 2002).
Research has suggested that LGBPs of color who are not open about
their sexual identity may be more likely to engage in sexual risk behav-
iors (Chng & Geliga-Vargas, 2000). Thus, ethnic minority LGBPs who
internalize stigma linked to their sexual orientation may be more likely
to engage in sexual risk behavior and less likely to talk openly about
their sexual behavior with health care providers. The link between dis-
closure of sexual orientation, risk behavior, and healthcare provider
attitudes around sexuality suggests that the removal of homophobic
attitudes from health care settings is pertinent to promote health
among LGB ethnic minorities.
3.3 Immigration Experiences and Their Effects on Health Care
Ethnic minority LGBPs who are immigrants to the United States
may face unique issues that affect their access to and utilization of the
American healthcare system. Findings from the National Survey of
America’s Families suggest that Black, Latino, and API immigrants are
much more likely to be uninsured than their citizen counterparts (Ku
& Waidmann, 2003). Research suggests that noncitizen immigrants are
more likely to be employed in low-income jobs that do not offer health
insurance benefits and are more likely to be concerned that enrolling
in public health care programs would jeopardize their residency status
compared to immigrants who are citizens and nonimmigrant citizens
(Ku & Waidmann, 2003; Yoshikawa & Lugo-Gil, 2004). As is discussed
in a later section of this chapter, changes in U.S. immigrant policies may
also explain the disproportionate number of immigrants who are
uninsured.
Research also suggests that immigrants are less likely to utilize the
healthcare system for reasons related to how they assess poor
health and their healthcare experiences in their country of origin. For
example, Chin et al. (2000) suggest that because of the way many Asian
American immigrants define poor or ailing health (i.e., as an extreme
dysfunction), they may be less likely to utilize the healthcare system
until their health and functioning is so impaired they can no longer
614 P.A. Wilson and H. Yoshikawa
fulfill their work and social roles. The same may be true for other immi-
grant groups. For instance, in a focus group study of Dominican,
Mexican, and Central American immigrants in New York City, Shedlin
and Shulman (2004) observed that many immigrants reported not
receiving treatment for health conditions until they were seriously ill.
Participants’ neglect of their health problems was based not only on
cultural values about what health problems warranted health-based
interventions but also a lack of experience in receiving preventive care.
For example, participants noted, “We are not even accustomed to
having milk for our children...we have to be [so] sick to seek serv-
ices [that] we cannot go backwards or ahead” (p. 439). Indeed, many
participants reported not seeking care until they were “falling down.”
Language can represent another barrier to receiving high-quality
health care that ethnic minority LGB immigrants may experience.
Many communities, notably those with large immigrant populations,
advertise health care programs in other languages (predominantly
Spanish) and have bilingual or multilingual healthcare providers.
Nonetheless, data suggest that non-English-speaking immigrants
access health care programs less frequently than English-speaking
immigrants and citizens (Ku & Waidmann, 2003). A great deal of
research on access to HIV prevention services has focused on the lan-
guage barriers faced by newly immigrated API and Latino gay men
who do not speak English as their primary language. Chng and Collins
(2000) noted that the numerous languages and dialects spoken by API
immigrants in the United States make HIV prevention interventions,
notably those that are mass-marketed, ineffective for many people in
this population. Furthermore, the translation of HIV prevention and
other health-based information from English to other languages may
result in a loss of information and/or inaccurate phrasing of messages,
as well as removal of the context in which the message should be
understood and interpreted. Language issues may also prevent aware-
ness of available healthcare programs among ethnic minority LGB
immigrants (Morales, 1990). Public health programs such as free HIV
testing, diabetes screening, and testing and treatment for other health
problems are often advertised only in English and are not promoted to
noncitizen immigrants, much less non-English-speaking immigrants.
Thus, to promote health among ethnic minority LGBPs who are immi-
grants and to reduce disparities in health care accessibility, it is impor-
tant to consider the difficulties immigrants have in achieving
high-quality health care.
4 Intervening at Different Levels of the Healthcare
System: Institutional, Community, and Policy
To improve access to health care among African-American, API, and
Latino LGBPs, interventions are needed to remove the barriers that
stand in the way between these groups and their receipt of high quality
health care. Many of the previously described barriers to health care
that LGB ethnic minorities experience can be eliminated through
25 Improving Access to Health Care 615
interventions occurring at different levels of the healthcare system:
institutional, community, and policy levels. It should be noted that
because of the nature of the problem we examine here (i.e., health dis-
parities and healthcare access among ethnic minority LGB persons) we
are interested in interventions that go beyond the individual and group
levels. Although these interventions are undoubtedly valuable in pro-
moting healthy behaviors in individuals, to achieve improved health
and healthcare access across an entire population we must implement
interventions that can reach entire communities.
4.1 Institutional Responses
We begin by examining intervention strategies at the institutional
levels. These interventions are our starting point because institutional
responses may need to occur before some community interventions
can be effectively implemented. There are three major institutional
responses necessary to promote healthcare access among ethnic minor-
ity LGBPs: (1) reduce the isolation of healthcare programs who are from
ethnic minority LGBPs; (2) train the healthcare professionals who are
delivering services and interventions; and (3) conduct research in
healthcare settings.
4.1.1 Reducing the Isolation of Healthcare Programs from
Ethnic Minority LGBPs
Reducing the isolation of healthcare programs from ethnic minority
LGBPs is of critical importance in our efforts to promote accessibility
to health care. Ethnic minority LGBPs live and work in diverse settings.
Some are in ethnic enclaves, others may live in low-income neighbor-
hoods, and still others may live in rural areas. However, many of the
health-related services targeting LGBPs, particularly those that are
resource-rich, are located in affluent, predominantly White communi-
ties. Notably, these services tend to be in “gay ghettos,” or neighbor-
hoods with a large population of LGBPs and/or a preponderance of
gay or lesbian bars, stores, and social organizations (e.g., the Castro in
San Francisco; Chelsea in New York City). In their four-city study com-
paring men living in gay ghettos and those living in other neigh-
borhoods, Mills and colleagues (2001) found that MSM living in
neighborhoods with a high concentration of same-sex households were
more likely to be White, identify as gay, and have a higher income than
MSM not living in neighborhoods with a large gay population. The
authors also observed that MSM living in gay ghettos were more likely
to have been tested for HIV, and posited that these MSM likely had
greater access to HIV prevention services. Similar findings have been
obtained in studies of ethnic minority LGBPs (Yoshikawa et al., 2002).
Thus, by not living in the neighborhoods in which services are located
and marketed, LGBPs of color may have limited access to health care
targeted to gays and lesbians. For this reason it is important that health
care programs for LGBPs be advertised in neighborhoods that do not
have the characteristics of a gay ghetto (i.e., a large number gay-iden-
tified persons, gay businesses, and so on) but have high proportions of
ethnic minority and/or immigrant populations. At a minimum, organ-
616 P.A. Wilson and H. Yoshikawa
izations located in gay ghettos that have programs focused on the
health needs of LGBPs should make an effort to locate satellite offices
in neighborhoods that house predominantly ethnic minority popula-
tions and/or persons of lower income status. It is also important that
HIV prevention and other interventions linked to LGB health provide
services to suburban, small city, and rural areas, which have been his-
torically overlooked in most HIV prevention interventions (Mancoske,
1997), though many of these areas are experiencing rapid growth in
ethnic minority and immigrant populations (Capps et al., 2003).
It is also important that existing healthcare-providing organizations
(i.e., hospitals, community health clinics) in neighborhoods with large
ethnic populations develop, implement, and market healthcare pro-
grams targeted toward LGBPs in the area. This requires eliminating
stigma and/or institutional discrimination toward gays and lesbians in
health organizations and increasing the resources available to these
organizations to develop health programs for LGBPs. Cultural sensi-
tivity trainings for medical professional and antidiscrimination policies
in health care organizations are important institutional interventions
that need to be implemented, as discussed later. Hospitals and clinics
can submit applications to obtain federal, state, and private sector
grants to aid in the development and implementation of health pro-
motion and prevention programs for ethnic minority LGBPs. Also, it is
important for healthcare organizations currently serving LGBPs of
color to make efforts to increase their accessibility to the target popu-
lation and broaden the services available. Research has shown that
ethnic minority LGBPs often believe that minority-focused health
organizations are not effective at achieving their goals of promoting
health and reducing risk among ethnic minority LGBPs largely due to
a lack of resources (Siegel & Raveis, 1997). A deficit of available
resources may translate into an organization’s limited hours of opera-
tion, lack of comprehensive services, and/or inadequate staff to carry
out interventions. With the difficulties involved in obtaining funding
to support or broaden community-based programs, it is of increasing
importance that healthcare organizations strengthen their grassroots
organizing efforts and volunteer programs, while developing their
ability to apply for and receive external grants.
Healthcare organizations also need to reach out to the ethnic minor-
ity LGBPs in the communities they serve by developing ties to existing
social groups and organizations in the community. Healthcare
providers should make an effort to be aware of the LGBP social groups
to the communities they serve so they can collaborate with these
groups to promote awareness of available healthcare programs avail-
able to LGBPs. Collaboration with community organizations is of dire
importance for hospitals and clinics serving largely minority popula-
tions, who may have an underground, but nonetheless active, gay and
lesbian social scene (Hawkeswood, 1996). For example, ethnic minor-
ity LGBPs have a strong presence in faith-based organizations, though
they may not be open about their sexuality (Woodyard et al., 2000).
Thus, it is important for healthcare organizations to collaborate with
churches and faith-based organizations in their efforts to treat ethnic
25 Improving Access to Health Care 617
minority LGBPs and inform them about health care programs tailored
to their needs. Offering HIV testing, cancer screening, and other diag-
nostic and preventive medical practices in churches, temples, and syn-
agogues are prime examples of how to achieve a collaborative effort
that links health and faith-based organizations. Also, it is important for
the staff delivering healthcare interventions to respect and support
patients’ use of religion and spirituality in coping with and treating
illness while providing formal health care and treatment.
LGB healthcare programs also need to be advertised in communities
with predominantly ethnic minority and/or immigrant populations,
which are frequently overlooked in HIV prevention and other LGB-
related health campaigns. Peterson and Carballo-Dieguez (2000)
recommended that innovative marketing campaigns deliver HIV pre-
vention messages directed toward both minority MSM and minority
heterosexual men in attempts to reach African American and Latino
MSM. This could help reduce the negative impact of what could be per-
ceived a “gay ad” by community members and make the message more
applicable to ethnic minority MSM who do not identify as gay or bisex-
ual. Similar social marketing and advertising campaigns are needed in
immigrant communities and rural areas. Healthcare organizations
should advertise programs for LGBPs and conduct outreach programs
in venues that may not be commonly understood as places were LGBPs
congregate. For example, Yoshikawa and colleagues (2002) noted that
HIV prevention interventions targeting Chinese immigrants in New
York City were successful when the outreaching was done at ethnic
grocery stores and Chinatown pharmacies—social settings with high
degrees of interaction and community trust. Thus, successful health-
care interventions are those that make a strong effort to advertise pro-
grams in ethnic communities and develop healthcare programs in these
communities to promote access to health care among ethnic minority
LGBPs.
4.1.2 Training Healthcare Professionals Delivering Services
and Interventions
As noted previously, it is important that healthcare providers are
trained to be sensitive to ethnic minorities and LGBPs. Government-
sponsored training on human subject protection, antidiscrimination
policies in clinical trials and health-related research projects, and other
similar training is not enough for health care professionals who deliver
services and interventions to ethnic minority LGBPs. Health care pro-
fessionals must be well versed with regard to the LGBP population
living, working, and socializing in the communities in which they
work. Do predominantly lesbians live in one area of the neighborhood?
Are there locations in the community where ethnic minority MSM
congregate and/or have sexual encounters? Are LGBPs likely to be
stigmatized in the community and unlikely to disclose their sexual
orientation? These are all questions that need to be asked and answered
by healthcare providers. Healthcare professionals need to understand
why ethnic minority LGBP may be uncomfortable in healthcare
settings and address their own prejudices and issues surrounding
homosexuality and ethnic diversity (Dowd, 1994; Parés-Avila &
618 P.A. Wilson and H. Yoshikawa
Montano-López, 1994). Healthcare organizations must ensure that the
staff delivering services and interventions can effectively work with
people of all sexual orientations, ethnicities, and socioeconomic status.
It is also important that organizations ensure that the health care
providers are aware of the diversity extant in the gay community and
work to reduce the preconceptions and stereotypes many providers
have about LGBPs (Greene, 1997; Brotman et al., 2002). Several inter-
ventions have shown to be effective for increasing the cultural compe-
tence of healthcare professionals, though none have specifically
addressed cultural sensitivity when working with ethnic minority LGB
populations. However, these interventions contain features that can be
employed by healthcare organizations when training staff to work
with LGBPs of color. For example, Holland and Courtney (1998)
observed three major strategies that can effectively increase cultural
competence among healthcare professionals: increasing educational
awareness; employing workers who are members of diverse ethnic and
cultural groups; and creating a cultural immersion experience for the
workers. Cultural immersion experiences may be the most important
way to promote openness and respect for diversity among staff deliv-
ering health care to LGBPs of color. Effective interventions of this type
have included inviting ethnic minority LGB community members to
share experiences and engage in discussions with staff (Neville et al.,
1996; Doutrich & Storey, 2004) and have taken the form of even more
creative approaches such as going into ethnic minority and/or LGB
neighborhoods for “scavenger hunts” that allow staff to be exposed to
prominent persons and places in the community (Holland & Courtney,
1998).
Healthcare providers must be trained not only to respect the diver-
sity of ethnic minority LGBPs but to meet clients “where they are.” As
previously noted, ethnic minority LGBPs are less likely than white
LGBPs to disclose their sexual orientation to health care providers
(Klitzman & Greenberg, 2002; Chng et al., 2003). Thus, healthcare
providers need to be aware that not all of their patients, particularly
those who are in ethnic minorities, will be forthcoming with regard
to their sexual behaviors. Similarly, providers need to learn sexual
history-taking techniques and be taught to screen for HIV and STIs on
the basis of risk behaviors, not the risk group (Wheeler, 2003). For
example, Malebranche and colleagues (2004) stated, “screen[ing] for
HIV risk by targeting risk groups like ‘BMSM [Black MSM];’ straight,
or gay, in essence, tells a patient they are at risk because of who they
are and may make them fearful to engage medical facilities for diag-
nosis just based on their demographic profile” (p. 104). The authors
noted that screening for risk groups may perpetuate fear-based mis-
communication of risky sexual practices to healthcare providers. The
American Medical Association reported that only about one-third of
primary care physicians report routinely taking a sexual history from
a new adult patient (Council on Scientific Affairs, 1996). Physicians
who do not determine their patients’ sexual orientation and sexual
behaviors deter patients from confiding in them and overlook possibly
important health risk factors. Thus, it is of paramount importance
that healthcare professionals talk with their clients about sexual
25 Improving Access to Health Care 619
health while maintaining a nonjudgmental attitude and ensuring
confidentiality.
Last, healthcare professionals should be aware of and adhere to
the 14 Community Standards of Practice for the Provision of Quality
Health Care Services for LGBT Clients (derived from the LGBT Health
Access Project, an intervention aimed at reducing health disparities in
LGBP living in Massachusetts) (Table 1). The Standards were reported
620 P.A. Wilson and H. Yoshikawa
Table 1. Community Standards of Practice for the Provision of Quality Healthcare
Services for LGBT Clients
Standard 1: The agency shall establish, promote and effectively communicate an inclusive,
nondiscriminatory work place environment for LGBT employees.
Standard 2: The agency shall support and encourage visibility of LGBT employees.
Standard 3: The agency shall work toward ensuring that LGBT employees of all ages are
subject to the same terms of employment as all other employees.
Standard 4: The agency shall assure that comprehensive policies are implemented to prohibit
discrimination in the delivery of services to LGBT clients and their families. The
agency shall ensure that all staff use, and all written forms and policies employ,
culturally appropriate language when dealing with LGBT clients and their
families. For the purpose of these standards the terms “family” and “families”
shall be broadly construed and shall include but not be limited to relatives by
blood, adoption, marriage, or declaration of domestic partnership.
Standard 5: The agency shall ensure that it has comprehensive and easily accessible procedures
in place for clients to file and resolve complaints alleging violations of these
policies.
Standard 6: The agency shall develop and implement or revise existing intake and assessment
procedures to ensure that they meet the needs of LGBT clients of all ages and their
families.
Standard 7: All agency staff shall have a basic familiarity with LGBT issues as they pertain to
services provided by the agency.
Standard 8: All direct care staff shall routinely provide general care to LGBT clients. All direct
care staff shall be competent to identify and address, within the scope of their field
of expertise, specific health problems and treatment issues for LGBT clients and
their families, to provide treatment accordingly, and to provide appropriate
referrals when necessary.
Standard 9: All case management and treatment plans shall include and address sexual
orientation and gender identity where it is a necessary and appropriate issue in
client care.
Standard 10: The agency shall ensure the confidentiality of client data, including information
about sexual orientation and gender identity issues. LGBT clients shall be
informed about data collection that includes references to sexual orientation and/or
gender identity, including in what circumstances such information may be
disclosed, whether it may be disclosed as aggregate or individual information,
whether personal identifiers may be disclosed, and how and by whom such
information may be used.
Standard 11: The agency shall provide appropriate, safe, and confidential treatment to LGBT
minors unless the agency’s services are inappropriate for all minors. All clients
who are minors shall be informed of their legal rights and advised of the
possibility and possible consequences of any statutory or otherwise mandated
reporting.
Standard 12: The agency shall include LGBT people and their families in outreach and health
promotion efforts.
Standard 13: The composition of the agency Board of Directors and other institutional bodies
shall encourage representation from LGBT communities.
Standard 14: Agency community benefits programs shall include LGBT people in the
communities the agency serves.
in the GLMA report on LGBT health in the United States, which was
made as a supplement to the national Healthy People 2010 policy ini-
tiative (GLMA, 2001). These Standards of Practice represent a compre-
hensive set of policies that health care organizations can implement to
better serve LGBPs. They cover employment and staffing issues, con-
fidentiality, intake and assessment procedures, and the rights of young
LGBPs, among other topics pertinent of LGB health. Health care organ-
izations that adopt the Community Standards of Practice are likely to
have success in reaching and promoting health among all LGBPs,
(member of an ethnic minority or otherwise). Currently, there are no
estimates of the proportion of hospital, clinics, and/or physicians’
offices that follow the Standards of Practice (J. Schneider, MD, GLMA,
personal communication, January 21, 2005). However, the available
data on experiences of antigay discrimination that LGBPs have in
health care settings suggest that more work needs to be done to imple-
ment these standards in healthcare organizations.
4.1.3 Conducting Research in Healthcare Settings
To promote access to health care among ethnic minority LGBPs it is
important for healthcare organizations to conduct in-house research,
such as needs assessments and program evaluations. Hospitals, clinics,
and other community-based health programs must make an effort to
collaborate with researchers in designing research projects that aid in
targeting ethnic minority LGBPs and developing effective and relevant
health programs for men and women in the population. Likewise, it is
imperative that researchers with expertise in working with ethnic
minority LGB populations and conducting research in Community-
based organizations (CBOs) and healthcare settings seek out health-
care organizations in an effort to create partnerships and foster
collaborative relationships. Healthcare organizations should focus on
not only treating health problems that may be unique to or most preva-
lent among ethnic minority LGBPs but also gaining broader knowledge
of the health issues affecting African American, Latino, and API LGBPs.
To provide a high level of care to LGBPs of color, healthcare profes-
sionals can review contemporary epidemiologic and other health
research relevant to these populations and, through implementing
needs assessments, collect data that can be used to describe the unique
population of LGBPs in the communities in which they work. Similarly,
periodic program evaluation ought to be an instrumental part of any
health care program regardless of whether it takes the form of a free-
standing intervention or is a component of a larger program in a hos-
pital or clinic. It is important that when engaging in research work
healthcare organizations are conscious of community attitudes toward
health-based research work and employ sampling procedures that
ensure all persons in the community have their voices heard, paying
close attention to the representation of LGBPs of color. As has been sug-
gested before, collaboration with community and social organizations
when conducting needs assessments and program evaluations may be
of particular importance. When conducting research, healthcare organ-
izations must ensure that the assessment techniques and instruments
25 Improving Access to Health Care 621
employed do not disenfranchise ethnic minorities and/or immigrants,
and they must put procedures in place that ensure the confidentiality
of participants’ personal information and data (Wheeler, 2003). Proper
informed consent is of paramount importance for all research partici-
pants, but particularly ethnic minority LGBPs, who may be more dis-
trustful of researchers than White LGBPs. Successful research projects
implemented by health organizations are those that are conducted with
LGBPs of color who feel comfortable participating in research studies,
are completely clear about how their information will be used, and
understand the purpose of the research project.
4.2 Community Responses
We suggest three actions that can be taken by community-level inter-
ventions to promote healthcare access among ethnic minority LGBPs:
(1) increasing comfort and trust with the health care system; (2) taking
into account folk models of “good health”; and (3) increasing the
number of ethnic minority and LGB healthcare professionals.
4.2.1 Increasing Comfort and Trust in the Healthcare System
As indicated earlier, ethnic minority LGBPs are more likely to be dis-
trustful with medical and mental health professionals and more ap-
prehensive when receiving care from health care professionals they
perceive to be racist and/or homophobic. Thus, it is important for inter-
ventions to address these concerns by working to increase comfort with
and trust of the modern healthcare system and healthcare profes-
sionals. This can be achieved through promoting the disclosure of
sexual behavior to health care providers and the utilization of available
healthcare programs, as well as through increasing comfort in access-
ing services for LGB immigrants who are not citizens or are undocu-
mented. It should be noted that these interventions cannot be effective
if healthcare providers serving LGBPs of color are homophobic and/or
racist. Encouraging the utilization of healthcare organizations that are
insensitive to the needs of ethnic minorities and LGBP only exacerbates
health disparities. Thus, institutional interventions that aim to train
healthcare professionals to be culturally sensitive and competent in
working with ethnic minorities and LGBPs must take place for com-
munity interventions to increase comfort and trust in the healthcare
system successfully among ethnic minority LGBP.
For LGB ethnic minorities to receive high-quality health care, it is
important for interventions to promote openness among ethnic minor-
ity LGBPs with regard to reporting their sexual behaviors and/or
sexual orientation to their healthcare providers. Although it is a diffi-
cult task for interventions to change deep-rooted social norms and
promote “coming out” in ethnic communities that may stigmatize
homosexual behaviors, these interventions can encourage ethnic
minority LGBPs to disclose their sexual behaviors in certain health con-
texts (e.g., to medical doctors and mental health professionals). When
promoting openness about health-related behaviors (such as substance
use and sex), it is important for LGB ethnic minorities to be aware of
confidentiality policies regarding nondisclosure of information about
622 P.A. Wilson and H. Yoshikawa
their behavior to other people or institutions (Wheeler, 2003). Educa-
tional campaigns that work to help ethnic minority LGBPs understand
the changes that have been made to the U.S. healthcare and research
systems, such as laws surrounding the protection of human subjects
and the promotion of ethical research, could be highly effective in
reducing distrust of the system. Similarly, it is important for ethnic
minority LGBPs to not feel like outsiders to the healthcare system.
Interventions must aim to develop collaboration between health care
organizations and community members and to foster relationships
between healthcare organizations and ethnic minority LGBPs. This
could be achieved by linking ethnic and/or LGB social groups to hos-
pitals, clinics, and treatment centers, organizing community health
fairs, and providing referrals for ethnic minority LGBPs to healthcare
providers. By showing LGB ethnic minorities that there are contexts in
which it is not only acceptable to discuss their sexual behavior openly
but ultimately advantageous for their good or improved health, it is
possible to address some of the discomfort those in this population may
experience in being forthright with the healthcare professionals with
whom they interact. Several mechanisms used in HIV/AIDS preven-
tion interventions that have been shown to have community-level
impacts may be useful to accomplish the goal of increasing ethnic
minority LGBPs’ comfort with the healthcare system and allow for
greater openness among LGBPs of color and their health providers.
These mechanisms include (1) enlisting community leaders to aid in
bridging ethnic minority LGBPs and health organizations (e.g., the
multisite AIDS Community Demonstration Projects) (Higgins et al.,
1996); (2) employing media campaigns designed for ethnic minority
LGBPs (Myrick, 1999); and (3) utilizing the “diffusion of innovations”
theory (Rogers, 1995) in community settings by identifying opinion
leaders and training them to deliver health- and prevention-related
messages to members of their networks. Diffusion models have been
effectively implemented in the form of popular opinion leader inter-
ventions taking place in gay bars (Kelly et al., 1997), low-income
housing projects (Sikkema et al., 2000), and small communities of MSM
in the United States (Kegeles et al., 1996) and Russia (Amirkhanian
et al., 2003).
Many ethnic minority LGBPs are aware of health programs in which
they may be able to participate, but they do not utilize these programs
even when facing ailing health (Morales, 1990; Shedlin & Shulman,
2004). Therefore, community interventions must focus at least partially
on promoting healthcare service utilization among ethnic minority
LGBPs. Nonutilization of programs may stem from the expectation that
the health care will be too costly, a lack of health insurance, or the per-
ception of a minimal need for health-related advice from others, as well
as a variety of other factors. Informational campaigns are needed that
not only let ethnic minority LGBPs know about available health care
programs and programs but make them aware of any costs or require-
ments associated with utilizing services. Furthermore, community-
level interventions must help ethnic minority LGBPs engage in
preventive care and facilitate relationship-building among healthcare
25 Improving Access to Health Care 623
professionals and patients, so ethnic minority LGBPs feel comfortable
talking to healthcare professionals about their health and health-linked
behaviors. Interventions must focus not only on the target population
of LGBPs who are ethnic minorities but also their families, friends, and
colleagues, who can help support their increased utilization of health
care programs (Icard et al., 1992). Social marketing campaigns with
health-based messages may prove themselves effective by building on
existing networks of support. This is largely because ethnic minority
LGBPs may be more likely to engage in health preventive behaviors
and seek medical help before becoming very ill if they are told to seek
care by respected others, not solely by the public health system. Inter-
ventions that aim to create awareness of available health care programs
and encourage utilization of these programs could also be successful
in promoting access to health care. The common saying “knowledge is
power” applies here. By informing ethnic minority LGBPs about gay-
friendly healthcare providers and programs that would be sensitive to
their needs, interventions can enable ethnic minority LGBPs make
good choices about their health care providers. The creation of regional
guidebooks that list services targeted toward LGBPs and/or persons
of color, and medical offices with staff who are ethnic minorities and/or
LGBPs may be one good way to implement an effective information-
based intervention at the community level.
When increasing the level of comfort of the ethnic minority LGBP
experience when accessing health care, it is important to consider the
needs of LGBPs of color who are immigrants. Immigrant LGBPs have
unique needs with regard to the way they access and use health care.
As noted in an earlier section, this group of LGBPs may experience
major difficulties in accessing high-quality health care because of lan-
guage difficulties and poor translation of health-focused prevention
messages. Interventions are needed that can be effectively conducted
in the languages of prominent immigrant groups in the United States,
notably Spanish, Chinese dialects, Tagalog, Vietnamese, Korean, and
other languages that are not as nationally prevalent but that are spoken
by ethnic minority immigrants clustered in particular areas (e.g.,
Arabic, French, Portuguese, Japanese, Bengali, Hindi). To increase
access to health care successfully, interventions targeted toward LGBPs
who are immigrants may need to be carried out by similar others and
must be modeled in such a way that they not only respect, but inte-
grate, the culture and tradition of the immigrant group(s) targeted in
their interventions. For example, because many APIs maintain a strict
silence around sexuality (including topics related to sex, such as
condom use and HIV/STIs), interventions aimed in reducing HIV-risk
behaviors in this population have distributed condoms packaged in
ways to make them resemble Chinese New Year gifts (i.e., wrapped in
red packaging and with gold lettering), thereby making them more
palatable to immigrant APIs (Chng et al., 2003; Yoshikawa et al., 2003).
It is also important that interventions targeted toward immigrant
LGBPs address the discomfort many may feel when accessing health-
care programs based on their undocumented and/or illegal immigra-
624 P.A. Wilson and H. Yoshikawa
tion status. For some immigrants, the history of discriminatory policies
regarding immigration as well as the perception of negative national
attitudes toward immigrants who come from countries that have been
or are now considered political opponents of the United States (e.g.,
China, Vietnam, Cuba, Middle Eastern countries) may lead to distrust
of the U.S. public health system (Chng et al., 2003). Immigrants who
have not been granted citizenship may believe that accessing any
government-sponsored program (such as low-cost health clinics, free
HIV/STI screening) could make them a target for deportation
(Yoshikawa & Lugo-Gil, 2004). Identification as gay, lesbian, or bisex-
ual can cause further distress when accessing healthcare programs that
may reveal one’s undocumented immigration status. Many LGB immi-
grants seek asylum in the United States—they wish to live freely as
GLB individuals, without the heightened stigma they may face by
living in their home countries (Chng et al., 2003; Shedlin & Shulman,
2004). This may create heightened motivation to maintain anonymity
and not access health care programs that they perceive could result in
deportation. Thus, for interventions to be effective, they must promote
comfort with the U.S. healthcare system for all persons.
4.2.2 Taking into Account Folk Models of “Good Health”
To promote access to health care among LGBPs who are ethnic minori-
ties, it is important that community-level interventions acknowledge
and account for the meaning of “good health” among ethnic minority
populations. For some Americans, engaging in preventive health care
is the norm. From vaccinations given to infants and children to cancer
and high blood pressure screening for middle-aged adults, health care
is as much about prevention as it is treatment. This may not be the case,
however, for some ethnic minorities. Ethnic minority LGBPs are likely
to have been raised in communities that apply alternative models of
health promotion and disease treatment. For example, many Latinos
believe in folk healing traditions. Notably, Parés-Avila & Montano-
López (1994) highlight Curanderism as a common tradition among
Latinos originally from countries with strong indigenous influences
(e.g., Mexico). In Curanderism, prayers, massage, and herbs are used to
treat physical and emotional ailments. Similarly, some API cultures
employ non-Western medical techniques such as acupuncture and the
use of natural medicines, herbs, and extracts to treat physical and
mental ailments. Ethnic minorities are also more likely than Caucasians
to utilize nontraditional forms of medical care and to access members
of the community who may have not had medical training but are
nonetheless considered erudite in their assessment and treatment of
health problems. Based on the legacy of discrimination in the U.S.
public health system, African Americans and other minorities may be
more likely to trust nonmedically trained community members with
their health care than medical professionals who are demographically
different from them (Dowd, 1994). Community-level interventions
would be ill-advised to disregard these traditions or attempt to remove
or alter them, regardless of whether they can be empirically shown to
25 Improving Access to Health Care 625
be beneficial to the ethnic minorities employing them. Rather, inter-
ventions need to work with informal health providers within the target
population community and integrate them into health-based interven-
tions. Including respected community members who are understood
to have expertise in health care (regardless of whether they were
trained in Western-style educational settings) in health-based inter-
ventions not only acknowledges the importance of addressing the
health of ethnic minority LGBPs from a cultural perspective but also
gives the intervention a more trusted face, making ethnic minority
LGBPs more likely to access the intervention and utilize the programs
and services of the intervention (Brotman et al., 2002).
Many Latino and African American LGBPs place a strong focus on
religion with regard to health and the treatment of illness. Based on
their experience as stigmatized minority members, ethnic minority
LGBPs may be more likely to rely on religious and spiritual beliefs
during difficult times (Chatters et al., 1992). It is important that inter-
ventions encapsulate the spiritual and religious traditions of ethnic
minority LGBPs into health-based interventions. For many people,
prayer and spirituality represent much more powerful forms of treat-
ment than visiting a doctor’s office or taking medications. Many ethnic
minorities speak with members of the clergy or other spiritual leaders
before they talk to health care professionals when they are sick. Corre-
spondingly, many LGBPs of color are likely to turn to religion upon
receiving a poor health diagnosis, or they may choose to forego medical
treatment as a matter of faith. By integrating a spiritual perspective into
health-based interventions, ethnic minority LGBPs may be more likely
to utilize services available to them. Health service organizations
designed largely for White LGB populations may not be open to
these spiritual and religious traditions because of how homophobic
Christian religious institutions are perceived to be by their staff. Thus,
it is important that community interventions targeted to ethnic minor-
ity LGBPs educate them about health risks and treatments in ways that
respect religious beliefs. For these interventions to be effective, LGBPs
of color cannot be made to feel that institutionalized health care and
religion are mutually exclusive. Healthcare providers and religious
officials need to endorse one another and work together in promoting
health among ethnic minority LGBPs. Parish nursing programs, in
which registered professional nurses are embedded in church congre-
gations to provide health services and education to fellow parishioners
(Anderson, 2004), represent prime examples of how religious and
health organizations can collaborate to achieve the common goal of
promoting health among ethnic minority LGBPs. Although churches
with predominantly ethnic minority memberships have been shown to
offer several social and health services, few have implemented pro-
grams that integrate formal healthcare services into the church setting
(Blank et al., 2002) even though these programs are frequently per-
ceived to be highly desirable among many minority parishioners
(Madison & McGadney, 2000; Wallace et al., 2002). Thus, it would be
wise for interventions to promoting parish nursing in congregations
that may include ethnic minority LGBP members.
626 P.A. Wilson and H. Yoshikawa
4.2.3 Increasing the Number of Ethnic Minority and
LGB Healthcare Professionals
Community interventions aimed at increasing healthcare access among
ethnic minority LGBPs could achieve this goal by aggressively recruit-
ing ethnic minorities and/or LGBPs to work in the healthcare indus-
try. Research has shown that ethnic minority patients are more likely
to feel comfortable and report satisfaction with medical professionals
who share their ethnic/racial background (Saha et al., 2003; Blanchard
& Lurie, 2004). Ethnic minority healthcare providers allow many of
their same-ethnicity patients to feel a sense of personal connection with
their provider, which is important to the access to and utilization of
health care. For example, a participant in Malebranche and colleagues’
(2004) study of perceptions of healthcare organizations among African
American MSM noted:
Black male doctors, because I am a Black male, have always been easier for me
to relate to. My doctor now says, ‘What have you been eatin’?’ And I say,
‘McDonalds.’ He says, ‘Brother, you need to cut that out.’ You know, they get
real with you. [p. 103]
Similarly, LGBPs report being more comfortable accessing healthcare
programs when they are treated by other LGB medical professionals
(Klitzman & Greenberg, 2002). Currently, there is a shortage of ethnic
minority and LGBP health care professionals (Cooper & Powe, 2004),
which affects ethnic minority LGBPs in two ways. First, the likelihood
that LGBPs of color will access health care and/or build a relationship
with a health care provider is diminished in the absence of a diverse
group of medical professionals. Second, because minority healthcare
providers are more likely than White physicians to serve minority
patients and to work in underserved areas, ethnic minority LGBPs may
have fewer opportunities to receive care (American Medical Associa-
tion, 1999). Interventions are desperately needed to promote diversity
among healthcare professionals. The American Association of Medical
Colleges (2002) reported that the number of minority medical school
graduates has steadily decreased over the past decade, most notably in
states that have overturned affirmative action laws. Interventions
to increase the number of minority healthcare professionals must
take place at multiple levels—at the community, institutional, and
policy levels. However, community interventions that mobilize
ethnic minorities and LBGPs to enter medical professions, offer train-
ing to increase the probability of acceptance into educational programs,
and provide access to scholarships or other forms of financial
support for higher education may be most effective at helping to create
a more diverse population of medical professionals in the United
States.
4.3 Policy Responses
Major policy responses to racial or ethnic disparities in healthcare
access among LGBPs, based on the evidence reviewed in this chapter,
25 Improving Access to Health Care 627
encompass health insurance and HIV/AIDS treatment policy. We
discuss each of these in this section.
4.3.1 Reduce Disparities in Health Insurance Access
The federal welfare reform legislation of 1996 (the Personal Responsi-
bility and Work Opportunity Reconciliation Act, or PRWORA) sharply
restricted eligibility for federal means-tested programs for immigrants
arriving in the United States after 1996. Guidelines differ by program
(Capps et al., 2002; Singer, 2004). Postenactment immigrants are ineli-
gible for Medicaid (except for Medicaid-funded emergency care and
the State Children’s Health Insurance Program, or SCHIP) for their first
5 years after coming to the United States. For SSI (Supplemental Secu-
rity Income—cash assistance for low-income elderly and disabled
persons), postenactment legal immigrants are simply ineligible, no
matter how long they are in the United States. To receive Food Stamps,
legal immigrants must prove that they have worked at least 10 years
in the United States. A few select groups are not subject to these restric-
tions (refugees or asylees during the first 7 years after entry; children
who arrived before 1996, and some elderly or disabled). States can
provide their own funding to replace these programs for postenact-
ment immigrants (Zimmerman & Tumlin, 1999).
To the extent that LGB communities of color have higher proportions
of immigrants, as well as lower incomes, than White LGB communi-
ties, they have borne a greater share of the burden of government-
directed exclusion from Medicaid and SSI. Although some states have
been relatively generous in substituting their own programs, there is
great variability among the 50 states (Zimmerman & Tumlin, 1999).
This has created obvious inequities based solely on residence for LGB
immigrants arriving after 1996. It is likely that PRWORA exacerbated
racial/ethnic disparities among low-income citizens in health care
access indicators, such as seeing a doctor in the last year. Ku and
Waidmann (2003) found, for example, that 67% of low-income White
U.S. citizens reported having seen a doctor during the last year com-
pared to 49% for Latino noncitizens who spoke English as their primary
language and an even lower 36% among Latino noncitizens who spoke
Spanish. The 1996 law has had, according to some, a “chilling” effect
on utilization of Medicaid and other means-tested benefits, even
among those eligible (e.g., immigrants who arrived before 1996) (Capps
et al., 2002). Recent studies of low-income immigrants have found that
even those legal permanent residents who are eligible for benefits avoid
using them for fear of future consequences for their applications for cit-
izenship (Yoshikawa & Lugo-Gil, 2004). These fears are expressed
despite current Immigration and Naturalization Service (INS) guide-
lines indicating that use of Medicaid and other government assistance
programs cannot be a reason to deny a legal immigrant citizenship.
The picture of Medicaid eligibility for undocumented immigrants is,
not surprisingly, more bleak than for legal immigrants. Undocumented
persons are not eligible for any care under Medicaid except emergency
care. LGB populations who are undocumented are thus likely to receive
health care only when they are so sick they cannot work. Because LGB
628 P.A. Wilson and H. Yoshikawa
populations who are undocumented are more likely to be Latino or
Asian than White, this federal policy almost certainly exacerbates
racial/ethnic disparities in health outcomes among LGBPs.
As is the case with benefits for legal immigrants, states have to
varying degrees stepped in with state-funded programs for which
undocumented immigrants are eligible. For example, New York State
allows them to receive prenatal and postnatal care in addition to emer-
gency care. However, no state allows undocumented immigrants to
receive the full range of Medicaid benefits, including HIV prophylaxis
and treatment.
The simplest policy solution to state-level inequities in eligibility for
Medicaid is to roll back exclusion of legal immigrants from federal
means-tested benefits. This was accomplished for Food Stamps soon
after passage of PRWORA owing to the outcry over the immigrant pro-
visions of the law. However, the exclusion from Medicaid has not been
addressed at the federal level. Rolling back exclusionary policies in the
area of nutrition but not health does not make sense from a public
health perspective. Disparities in healthcare utilization among low-
income LGB communities of color would be most fundamentally
addressed by extending Medicaid eligibility to all residents of the
United States.
4.3.2 Address HIV/AIDS Prevention and Treatment Disparities
Disparities across racial/ethnic groups have been found in the use of
federally funded HIV treatment programs. The disparities may be
particularly strong among LGB populations owing to their higher
incidence of HIV and AIDS. However, no studies have examined
racial/ethnic differences in HIV treatment access among LGBPs. We
therefore rely here on more general data across race/ethnicity, regard-
less of sexual orientation or identity.
The two major federally funded programs providing coverage of
HIV treatments are the AIDS Drug Assistance Program (ADAP) and
Medicaid. Both provide assistance in obtaining highly active antiretro-
viral treatment (HAART) and other advanced HIV/AIDS treatments,
as well as prophylaxis. Medicaid coverage of HIV-related drugs is gen-
erally limited to low-income individuals relative to ADAP. National
data from 1998 showed that HIV-positive African Americans are sub-
stantially less likely to make use of ADAP than HIV-positive members
of other racial/ethnic groups (Morin et al., 2002). This may be because
African Americans are more likely to have low income and therefore
are more likely to receive HIV treatment through Medicaid. However,
according to a review of studies dating back to 1985, non-White pop-
ulations were less likely to use antiretroviral drugs than White popu-
lations in most of the studies (Palacio et al., 2002). These data suggest
that disparities across racial/ethnic groups in treatment utilization are
longstanding and occur regardless of the specific program being
considered.
As we have seen, Medicaid eligibility for legal immigrants differs
considerably across states. Medicaid coverage guidelines for HIV treat-
ment also differ substantially. In an analysis performed in 2000 of
25 Improving Access to Health Care 629
policies regarding ADAP and Medicaid-funded AIDS treatment in the
four largest states, Morin et al. (2002) found large differences in policy
dimensions, such as the number of HIV treatment drugs covered for
reimbursement. California and New York did not limit the number of
drugs covered in any month for treatment. In contrast, Florida allowed
only four HIV drugs per month and Texas three. As a result, in Florida
and Texas, individuals with HIV and other co-occurring diseases
reported finding it difficult to have their complete prescribed set of
treatments covered by Medicaid. Eligibility guidelines also differed
across these state policies. Florida, Texas, and California all required
federal disability designation or welfare receipt as part of eligibility.
New York did not have these requirements.
ADAP policies differed even more drastically among the four states.
For example, ADAP drugs were available in 2000 at only 244 pharma-
cies in Texas, compared to more than 2000 in both California and New
York (a huge disparity even taking into account differences in popula-
tion among these states). California’s ADAP program covered use of
110 HIV-related drugs and New York 395, but in Florida only 26 such
drugs and in Texas only 19. Finally, income eligibility for ADAP in the
four states ranged from 200% to 400% of the federal poverty threshold.
Thus, large inequities exist in state-level ADAP and Medicaid poli-
cies regarding HAART and other HIV treatments. These inequities may
be implicated in state-level mortality disparities across racial/ethnic
groups (in three of the four stated studied by Morin et al., declines in
HIV/AIDS mortality across 1996 to 1998 were smaller among African
Americans than in Whites). In addition, across the four states, the per-
centage of individuals with AIDS diagnoses covered by Medicaid or
ADAP differed significantly, with New York covering more individu-
als through its two programs than the number of diagnosed (because
of its coverage of prophylactic medications, for example), and Texas
covering the smallest proportion (68%). As in the case of Medicaid eli-
gibility for immigrants, the simplest policy solution is to make HIV
treatment eligibility and drug coverage regulations equal across states
through federal law. Such regulations should be created for each of the
two major programs, ADAP and Medicaid.
In addition to policy regulation, federal support of community-based
efforts to increase utilization of ADAP and Medicaid among individu-
als of color affected by HIV should be increased. For low-income indi-
viduals coping with HIV/AIDS, for example, a recent set of studies
found that two policy steps are crucial for community-based outreach
to communities of color affected by HIV/AIDS (Richards et al., 2002).
The first is to ensure that the take-up of HIV-related services occurred
at the critical juncture of the test result. Individuals who do not receive
services at that point often do not reappear until they have symptoms
of AIDS, at a point when prophylactic action is too late. The second is
to acknowledge that for low-income people affected by HIV/AIDS
problems with daily living and making ends meet often overwhelm
health and health promotion. Embedding HIV/AIDS care in the
context of other services that address the needs of the poor (e.g., income
support, employment, education, child care, and other services) was
630 P.A. Wilson and H. Yoshikawa
critical in this study to the success of the HIV/AIDS care (Richards et
al., 2002). Not surprisingly, states that were less generous in terms of
eligibility and coverage of HIV/AIDS treatments were also less com-
prehensive in meeting the needs of low-income populations in general.
Federal support of “one-stop” centers, such as those that have been
implemented in the area of job training and work support, could be
implemented to integrate health care coverage and services with other
services for the populations most at risk for HIV infection, more fre-
quent general poor health outcomes, and poverty. These persons are of
course more likely to be populations of color, and such policies are
likely to improve health outcomes among African American, Asian,
and Latino LGB people.
5 Summary
We have examined access to health care among African American, API,
and Latino lesbian, gay, and bisexual populations. Epidemiologic data
show that ethnic minority LGBPs are more likely to experience physi-
cal and mental health problems than heterosexuals and Caucasian
LGBPs. Indeed, ethnic LGBPs have higher rates of STIs, certain cancers,
depression, and substance use than other populations. Although
research explaining health disparities has been called for in U.S. gov-
ernment and community-based organizations, work specifically exam-
ining the needs of LGBPs of color has been scant. Nonetheless, the
available relevant studies suggest three major factors involved in
understanding ethnic minority LGBPs’ heightened risk for poor health
outcomes. They include the negative impact of discrimination on
health and risk behavior, racism and homophobia in health care and
research settings, and immigration experiences that may negatively
affect health care access and utilization. To be effective in reducing and
eliminating health disparities between minority and nonminority pop-
ulations in the United States it is of great importance that researchers,
health organizations, minority and/or LGB community-based organi-
zations, and policymakers make an effort to improve health care and
healthcare accessibility among LGBPs of color.
There are several ways in which interventions can improve access to
health care among LGBPs of color. These interventions may occur at
various levels of the healthcare system: institutional, community, and
policy levels. Institutional interventions are needed to reduce the iso-
lation of healthcare programs from ethnic minority LGBPs, train
healthcare professionals to be culturally sensitive to the needs of ethnic
minority LGBPs, and promote research on LGB populations in health-
care settings. Community-level interventions that aim to increase
ethnic minority LGBPs’ comfort for accessing the healthcare system
and trusting healthcare professionals, incorporate ethnic-centered
models of the meaning of good health into their services and programs,
and increase the number of ethnic minority and LGB healthcare pro-
fessionals are likely to be successful in promoting improved health care
for LGBPs of color. Finally, policy-level interventions are warranted
25 Improving Access to Health Care 631
that reduce disparities in health insurance access among ethnic minor-
ity LGBPs and improve access to HIV/AIDS prevention and treatment
services among LGBPs of color.
Health care is commonly understood to be a human right in the
United States; however, serious discrepancies in access to health care
make the receipt of health-related services a luxury for many, notably
those who belong to ethnic minorities. As research has shown, dispar-
ities in health care among LGBPs resemble those observed in the
general U.S. population—they both fall along ethnic and racial lines.
Thus, in our efforts to understand and promote health among all
people who are lesbian, gay, and bisexual, our goal must be to improve
access to high quality health care among African American, API,
and Latino LGBPs. Achieving this goal not only will help eliminate
health disparities in the United States, it will further the ultimate
objective of making the receipt of high quality health care a right of all
individuals.
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... Since the use of intersectionality has mostly occurred in qualitative research (Bauer 2014), our quantitative research design is expected to advance the study of intersectional identities and their relationship to health at the population level. Considering research that documents significant health disparities (Wilson and Yoshikawa 2007) as well as lower engagement in care (Brenick et al. 2017) among sexual minorities of color, our analyses will have implications for public health interventions by providing a useful lens to better understand the nuances of healthcare-related experience among U.S. adults, particularly those with multiple minority identities. ...
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Objectives: Existing scholarship has consistently demonstrated disparities in healthcare experience based on sexual identity. However, relatively little research has considered intersections with race/ethnicity, despite that intersection with other characteristics may complicate healthcare experiences and satisfaction among sexual minorities. This study aims to address such a gap by examining healthcare satisfaction across the intersections of sexual and racial/ethnic identity. Design: Utilizing data on U.S. adults included in the 2013-2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 372,766), we investigate levels of satisfaction with care among a range of groups simultaneously embodying two identities. Results: Findings from ordered logistic regression models show that among adults who identify as heterosexual, the odds of reporting high satisfaction with care are lower among Blacks, Asians, and Native Americans. Among sexual minority adults, the likelihood of reporting high satisfaction with care is consistently lower among Native American gay and lesbian adults compared to gays and lesbians of other race/ethnicity or Native American and White heterosexuals, indicating heightened vulnerability to poorer healthcare experience among this multiple minority group. Conclusion: While levels of satisfaction with care tend to be generally high across groups, future research should endeavor to investigate the driving factors that lower the odds of high healthcare satisfaction among those with intersecting minority identities.
... Our findings suggest the need to ensure that LSMM have access to resources to support their mental health and well-being as they continue to experience the brunt of two, co-occurring pandemics: COVID-19 and HIV, along with mental health/substance use disparities. Before the emergence of COVID-19, LSMM had inadequate access to culturally relevant, affirming mental health and substance use treatment services (McIntyre et al., 2012;Moe & Sparkman, 2015;Wilson & Yoshikawa, 2007). Prior to COVID-19, there was already a need to address gaps in the scale up and dissemination of these resources to LSMM. ...
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Introduction Sexual minority men face mental health, substance use, and HIV disparities, all of which can be understood by minority stress and intersectionality theories. With the emergence of COVID-19 and considering its disproportionate impact on Latinx and sexual minority communities, Latino sexual minority men (LSMM) may be facing unique consequences of this new pandemic that intersect with pre-COVID disparities. The purpose of the current study is to explore the impact of the COVID-19 pandemic on LSMM’s intersectional minority stress, general stress, and coping, filling a gap in the current literature. Methods The current rapid qualitative study explores the impact of COVID-19 on LSMM in South Florida who reported being HIV-negative (N = 10) or living with HIV (N = 10). Results The rapid analysis revealed themes of exacerbated intersectional minority stress and general stress in the context of COVID-19, some of which was related to the impact of pre-COVID-19 disparities in the LSMM community. Participants reported a variety of coping responses, some of which participants found helpful and others (e.g., substance use) which further exacerbated disparities. Conclusion The findings underscore the need to scale up and disseminate behavioral health resources to LSMM to address the impact of the COVID-19 pandemic on this community’s health and well-being.
... A range of items assessed anticipated, enacted, and internalized stigma on the basis of race and sexual orientation, in addition to perceived stigma from health care providers, and medical distrust [25,26]. ...
Article
Background Pre-exposure prophylaxis (PrEP) can sharply reduce HIV transmission risk, yet has not been widely adopted among those at highest risk for HIV, including Black men who have sex with men (BMSM). To better understand the evolving landscape of PrEP uptake in this at-risk population, we sought to examine psychosocial factors associated with PrEP uptake in a sample of BMSM residing in the Atlanta, GA, area.MethodBMSM were recruited through online social media, LGBT venues, and participant referral, and self-reported demographic and psychosocial information via computer-assisted self-interview. Multivariate logistic regression was used to examine psychosocial factors associated with PrEP uptake.ResultsIn 293 BMSM, most (N = 260; 88.7%) reported awareness of PrEP yet few (N = 30; 10.1%) reported ever having taken PrEP. BMSM reporting more syndemic conditions were less likely to be current PrEP users (OR = 0.59; 95% CI: 0.36, 0.96). BMSM reporting recent condomless anal sex (CAS) with a partner met online (adjusted odds ratio (aOR) = 2.53; 95% CI: 1.07, 5.93), or who reported having chlamydia (aOR = 8.21; 95% CI: 1.42, 47.67) or STI-related symptoms (aOR = 4.35; 95% CI: 1.32, 14.37) in the past 3 months, or genital warts in their lifetime (aOR = 7.74; 95% CI: 2.47, 24.21) were more likely to have ever used PrEP. Sexual orientation stigma from health care providers was negatively associated with PrEP uptake (OR = 0.81, 95% CI: 0.68, 0.95) among BMSM reporting recent CAS and multiple partners.Conclusion Syndemic and stigma theories may inform strategies for improving PrEP uptake in BMSM.
... The Healthy People 2010 initiative (HP2010) analyzed 28 different focus areas containing 467 measurable objectives of physical health from 2000 to 2010, and these objectives were updated for Healthy People 2020 (HP2020) [13]. Although research on the U.S. population shows that particular population groups are disproportionally affected by poor health outcomes and have less access to preventive care (e.g., individuals living below the poverty line, individuals in rural populations, and racial/ethnic/sexual minorities) [14][15][16][17][18], there has been very little research investigating the relative achievement of Healthy People objectives among military populations, and particularly military spouses. In a 2006 study, self-reported service members' health behaviors met or exceeded 7 of the 19 HP2010 objectives assessed, including those related to obesity and exercise [19]. ...
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Background: The health and well-being of military spouses directly contribute to a robust military force by enabling the spouse to better support the active duty member's career. In order to understand the overall health and well-being of military spouses, we assessed health indicators among military spouses using the Healthy People 2020 framework and examined associations of these health indicators with military experiences and psychosocial factors. Methods: Using data from the Millennium Cohort Family Study, a U.S. Department of Defense-sponsored survey of 9872 spouses of service members with 2-5 years of military service, we examined attainment of Healthy People 2020 goals for spouses and service members, including healthy weight, exercise, sleep, and alcohol and tobacco use. Multivariable logistic regression models assessed associations of spouse health indicators with stressful military life experiences and social support, adjusting for demographics and military descriptors. The spousal survey was administered nationwide in 2011. Results: The majority of military spouses met each health goal assessed. However, less than half met the healthy weight and the strength training goals. Reporting greater perceived family support from the military was associated with better behavioral health outcomes, while having no one to turn to for support was associated with poorer outcomes. Using the Healthy People 2020 objectives as a framework for identifying key health behaviors and benchmarks, this study identified factors, including military-specific experiences, that may contribute to physical health behaviors and outcomes among military spouses. With respect to demographic characteristics, the findings are consistent with other literature that women are more likely to refrain from risky substance use and that greater education is associated with better overall health outcomes. Conclusions: Findings suggest that enhanced social and military support and tailored programming for military spouses may improve health outcomes and contribute to the well-being of military couples. Such programming could also bolster force readiness and retention.
... But, LGB young people are more likely to report unmet need for services compared to heterosexuals (Williams & Chapman, 2011 and may delay seeking help for their mental health because they have fears of discrimination in healthcare settings (Craig & Smith, 2014;Hoffman, Freeman, & Swann, 2009). LGB individuals have reported negative experiences with providers related to their sexual identities (Jones & Gabriel, 1999;McCann & Sharek, 2014) that can lead to poor engagement with services (Eady, Dobinson, & Ross, 2011;Travers & Schneider, 1996;Willging, Salvador, & Kano, 2006), especially among LGB people of color (Wilson & Yoshikawa, 2007). Service providers vary in their respective LGB-related attitudes and competencies (Moe & Sparkman, 2015), and some mental health providers have not received sufficient, if any, education or training regarding the needs of LGB individuals (Long, Bonomo, Andrews, & Brown, 2006). ...
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The transition to adulthood presents particular challenges for Black and Latinx sexual minorities in need of mental health services. Identity formation and marginalization during this developmental period can interfere with help-seeking and lead to health disparities. Identity-specific psychosocial supports are needed to assist young adults to successfully navigate these challenges, but research on identity processes, help-seeking, and service-utilization among sexual minority young people of color is very limited. To better understand how multiple minority young people navigate their identities in the context of using, or choosing not to use, mental health services, this study qualitatively explored the experiences of 31 emerging adults. Through in-depth interviews, analyses revealed that young adults negotiated social identity norms about mental health help-seeking by separating from unhelpful norms, managing stigmatized aspects of identity, integrating helpful identity alternatives, and forming individualized perspectives on help-seeking that allowed them to maintain important connections to their minority group identities. Findings are discussed in relation to previous research on ethnic and sexual minority identity development and service utilization. Practice and research recommendations for increasing knowledge, improving help-seeking, and promoting resilience around young adults’ intersectional identities are offered.
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Purpose: This study evaluated the characteristics associated with sexual orientation disclosure among HIV-negative Black sexual minority men (BSMM) in the greater Atlanta, Georgia area. Survey data were collected from 475 HIV-negative BSMM from 2017 to 2019 as part of a larger behavioral intervention study focused on stigma, prejudice, and HIV-testing uptake. Methods: Participants reported their levels of sexual orientation disclosure globally, to their community, and to their family. Data were analyzed using one-way analysis of variance and multinomial logistic regression to determine whether demographic, minority stress, substance use, and mental health were associated with sexual orientation disclosure globally, to community members, and to family members. Results: Findings revealed that participants with older age, bisexual identity, and higher levels of internalized homophobia had higher odds of global, community, and family sexual orientation nondisclosure. Furthermore, participants with higher levels of resilience had lower odds of partial sexual orientation disclosure compared with their fully disclosed counterparts. Conclusions: These findings reveal variations associated with sexual orientation disclosure across varying contexts among HIV-negative BSMM, particularly among family member disclosure.
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Introduction Sexual minorities may experience sexual orientation-based discrimination in healthcare settings, and recent literature has aimed to explore this phenomenon. However, the findings of related literature and their implications have never been reviewed. Methods A scoping review was conducted to identify the breadth of this literature, summarize findings, and appraise the tools being used to study perceived discrimination in healthcare. PubMed and Web of Science databases were searched for relevant literature published between 1992 and 2022. After duplicates were removed, the search yielded 3,467 results. After removing articles that did not meet inclusion criteria, fifty-eight papers remained and were assessed via full-text review for eligibility. Ultimately, twenty studies were determined to meet study criteria and were included in the present review. Results Articles published on sexual orientation-based perceived discrimination in US healthcare settings are fairly limited and vary in approach. Measures being used vary widely across studies and generally lack psychometric grounding; common issues include using single-item measures, adapting existing measures without validating them for use in sexual minority samples, and using measures that are not based in underlying theory or informed by existing research. Perceived discrimination in healthcare was inversely associated with some healthcare utilization behaviors. Conclusions Future research should use psychometrically evaluated instruments for studying perceived discrimination in healthcare due to sexual orientation. Policy Implications Culturally competent policies that promote equitable care for sexual minorities are crucial for reducing discrimination in healthcare.
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This article identifies the extent to which deeply embedded ideas and beliefs about the innate normalcy of the man/woman gender binary feed longstanding attitudes against those persons whose gender identity is believed to be aberrant and pathological. The discrimination directed at LGBTQ + persons creates inequities that deepen their social marginalization and push them further away from the exercise of constitutional rights. This article urges public administration to create effective interventions to eliminate the racism and gender-identity hate and discrimination that continue to place an unfair burden on especially LGBTQ+ Black, Indigenous and other Persons of Color (BIPOC).
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This study explored turning points in health perceptions among lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults of color living in a major US city. Turning points in health perceptions were elicited from 38 participants through in-depth interviews and were examined using interpretive phenomenological analysis. Findings revealed three key themes: (a) diagnosis and disease; (b) death or illness of family and friends; and (c) changes in environmental context and body. The positive impacts of turning points are discussed, including the development of active coping skills, engagement in health-promoting behaviors, and increased community connectedness. Implications for future research are also suggested.
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Research identifying factors associated with treatment utilization of individuals at risk for suicide has been inconsistent. This study examines correlates of treatment utilization among depressed patients with and without a lifetime history of suicide attempt. In this retrospective chart review, 37 depressed adults registered to receive treatment at an outpatient clinic agreed to participate. Level of treatment utilization and sociodemographic and clinical characteristics were examined. Only having family support (r = −.324; p = .05) and having a history of physical abuse (r = −.384; p = .019) were associated with utilization. Findings highlight the important role of family and the clinician-client relationship as motivators for treatment utilization.
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This exploratory investigation assessed changes in perceived multicultural therapy competencies and level of White racial identity development following a multicultural course. Results indicate that completion of a diversity-related course appeared to increase trainees' multicultural therapy competencies and to facilitate the adoption of more sophisticated White racial identity ego statuses; these changes remained stable at a 1-year follow-up. Findings from the qualitative analyses underscore the importance of racially and ethnically diveise speakers and panels in promoting multicultural therapy competencies.
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Various authors have noted that interethnic group and intraethnic group racism are significant stressors for many African Americans. As such, intergroup and intragroup racism may play a role in the high rates of morbidity and mortality in this population. Yet, although scientific examinations of the effects of stress have proliferated, few researchers have explored the psychological, social, and physiological effects of perceived racism among African Americans. The purpose of this article was to outline a biopsychosocial model for perceived racism as a guide for future research. The first section of this article provides a brief overview of how racism has been conceptualized in the scientific literature. The second section reviews research exploring the existence of intergroup and intragroup racism. A contextual model for systematic studies of the biopsychosocial effects of perceived racism is then presented, along with recommendations for future research.
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Public health data indicate that the incidence of acquired immunodeficiency syndrome (AIDS) among racial and ethnic minority men who have sex with men (MSM) has been disproportionately high among African-American and Hispanic men in the United States.1 AIDS cases due to male-to-male sexual contact account for 39% of AIDS cases among African Americans and 43% among Hispanic Americans.2 Also, cross-sectional and cohort studies among these ethnic minority men have revealed they have maintained elevated levels of high-risk sexual behavior.3-8 These data suggest that more effective human immunodeficiency virus (HIV) prevention programs are needed among homosexual and bisexual racial and ethnic minority men to achieve the significant reductions in HIV transmission reported among white gay and bisexual men.9 However, notable differences between white and nonwhite MSM increase the difficulty to provide effective intervention programs to minority men. The emphasis on HIV transmission among minority heterosexuals diverts attention from the substantial route of HIV transmission through male-to-male sexual activity. Also, the opportunity for HIV prevention with minority MSM is greatly diminished by the influence of prejudice and discrimination toward nonwhite MSM by both minority culture and mainstream gay culture. Finally, these efforts are hampered by the lack of sufficient prevention research to guide further development of community programs. Despite these obstacles, such evidence is urgently needed to help provide directions for HIV prevention among minority MSM populations.