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Health Needs and Experiences of a LGBT Population in Georgia and South Carolina

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Abstract

The 2016 Municipal Equality Index rated Augusta, the largest city in the Central Savannah River Area (CSRA), as one of the least lesbian, gay, bisexual, and transgender (LGBT) friendly cities in America. To understand the context of our region in relation to LGBT wellness, we conducted the first LGBT health needs assessment of the CSRA, assessing physical and mental health status and health care needs and experiences in the community. Participants (N = 436) were recruited using venue and snowball sampling and completed an anonymous online survey. Overall, the health problems experienced (i.e., obesity, depression) were not uniformly experienced across sexual orientation and gender identity; some groups experienced significantly higher rates of these conditions than others. Similarly, transgender individuals in particular reported higher rates of negative experiences with health care providers. Regional and national dissemination of these findings is critical to reducing health disparities and improving wellness of our local LGBT community.
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Journal of Homosexuality
ISSN: 0091-8369 (Print) 1540-3602 (Online) Journal homepage: http://www.tandfonline.com/loi/wjhm20
Health Needs and Experiences of a LGBT
Population in Georgia and South Carolina
Lara M. Stepleman, Jiby Yohannan, Samantha M. Scott, Lauren L. Titus, Joan
Walker, Eliot J. Lopez, Lauren Wooten Smith, Alexis L. Rossi, Thomas M.
Toomey & Elizabeth D. Eldridge
To cite this article: Lara M. Stepleman, Jiby Yohannan, Samantha M. Scott, Lauren L. Titus, Joan
Walker, Eliot J. Lopez, Lauren Wooten Smith, Alexis L. Rossi, Thomas M. Toomey & Elizabeth
D. Eldridge (2018): Health Needs and Experiences of a LGBT Population in Georgia and South
Carolina, Journal of Homosexuality
To link to this article: https://doi.org/10.1080/00918369.2018.1490573
Published online: 10 Aug 2018.
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Health Needs and Experiences of a LGBT Population in
Georgia and South Carolina
Lara M. Stepleman, PhD
a
, Jiby Yohannan, BS
b
, Samantha M. Scott, MPH
b
,
Lauren L. Titus, BS
b
, Joan Walker, MPH
b
, Eliot J. Lopez, PhD
c
,
Lauren Wooten Smith, MPH
b
, Alexis L. Rossi, PhD
b
, Thomas M. Toomey, BA
b
,
and Elizabeth D. Eldridge, PhD
a
a
Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University,
Augusta, Georgia, USA;
b
Medical College of Georgia, Augusta University, Augusta, Georgia, USA;
c
Department of Psychiatry, University of Texas Health Sciences Center San Antonio, San Antonio,
Texas, USA
ABSTRACT
The 2016 Municipal Equality Index rated Augusta, the largest
city in the Central Savannah River Area (CSRA), as one of the
least lesbian, gay, bisexual, and transgender (LGBT) friendly
cities in America. To understand the context of our region in
relation to LGBT wellness, we conducted the first LGBT health
needs assessment of the CSRA, assessing physical and mental
health status and health care needs and experiences in the
community. Participants (N= 436) were recruited using venue
and snowball sampling and completed an anonymous online
survey. Overall, the health problems experienced (i.e., obesity,
depression) were not uniformly experienced across sexual
orientation and gender identity; some groups experienced
significantly higher rates of these conditions than others.
Similarly, transgender individuals in particular reported higher
rates of negative experiences with health care providers.
Regional and national dissemination of these findings is critical
to reducing health disparities and improving wellness of our
local LGBT community.
KEYWORDS
LGBT; physical health;
mental health; southeast;
needs assessment; health
disparities
Lesbian, gay, bisexual, and transgender (LGBT) individuals are receiving
increased focus, both nationally and internationally, as an at-risk population
for specific health conditions (National Institutes of Health [NIH], 2010). This
area of emphasis follows decades of research describing barriers to care for
LGBT individuals. Additionally, the Centers for Disease Control and Prevention
(CDC) has identified sexual and gender minorities as a health disparate and
underserved group (Centers for Disease Control and Prevention [CDC], 2016b).
Health disparities arise from a number of converging factors, including poor
access to LGBT-competent providers and differences in insurance coverage, as
well as risky health behaviors and care delays associated with stigma, oppression,
CONTACT Lara M. Stepleman lsteplem@augusta.edu Department of Psychiatry and Health Behavior,
Medical College of Georgia, Augusta University, 997 St. Sebastian Way, Augusta, GA 30912, USA.
JOURNAL OF HOMOSEXUALITY
https://doi.org/10.1080/00918369.2018.1490573
© 2018 Taylor & Francis
and discrimination related to sexual orientation and gender identity minority
status (McKay, 2011). To address the importance of identifying and reducing
these disparities, the current study aimed to explore the mental and physical
health experiences and needs of LGBT individuals in a largely rural area of the
Southern United States.
Researchers have identified numerous examples of physical health dispa-
rities among LGBT individuals, such as lesbian and bisexual women having
higher rates of obesity and asthma, as well as lower utilization rates of cancer
prevention services (Cochran & Mays, 2007; Dilley, Simmons, Boysun,
Pizacani, & Stark, 2010; Valanis et al., 2000). Further, bisexual women may
be more likely to have diabetes compared to heterosexual women, while
bisexual men and women may have higher risk profiles, including increased
odds for diabetes and hypertension (Dilley et al., 2010). Higher rates of HIV
and other sexually transmitted infections have been found among gay and
bisexual men (CDC, 2016b) and transgender women (Herbst et al., 2008).
Additionally, LGBT populations have been identified in some studies to have
greater rates of risky health behaviors, including tobacco, alcohol, and other
substance use, which have largely been tied to persistent experiences of
minority stress (Hughes, Wilsnack, & Kantor, 2016; Kerridge et al., 2017;
Lee, Griffin, & Melvin, 2009).
In addition to physical health, LGBT populations have been found to have
poorer mental health compared to heterosexual, cisgender counterparts, which
has also been associated with stigma and minority stress (Dilley et al., 2010).
Meta-analyses have identified an increased risk of suicide attempts, depression,
anxiety, and substance use disorders for lesbian, gay, and bisexual individuals,
with lesbian and bisexual women at particular risk of substance use disorders
and gay and bisexual men at particular risk for lifetime suicide attempts (King
et al., 2008). Compared to heterosexual individuals, higher rates of depression,
panic attacks, and body image and eating disorders have been found in sexual
minoritymen in contrast to higher rates of generalized anxiety disorder in sexual
minority women (Cochran, Sullivan, & Mays, 2003; Mayer et al., 2008).
Furthermore, literature has shown that gender minorities, in comparison to
cisgender individuals, experience higher prevalence rates of depression, anxiety,
and somatization concerns (Bockting, Miner, Swinburne Romine, Hamilton, &
Coleman, 2013).
Contributing to the complex underpinnings of these health disparities, LGBT
individuals are less likely to have insurance and more likely to experience diffi-
culties accessing health care, the latter of which is not fully explainedbydifferences
in health insurance (Buchmueller & Carpenter, 2010;Daniel&Butkus,2015).
LGBT individuals are also more likely to avoid necessary medical care, potentially
due to discrimination and heteronormative assumptions within the health care
system that can marginalize LGBT individuals and families (Khalili, Leung, &
2L. M. STEPLEMAN ET AL.
Diamant, 2015;Smith,2015). Healthy People 2020 declared a shortage of LGBT-
competent providers, with some studies also finding higher rates of discrimination
and mistreatment by providers among LGBT individuals compared to cisgender
and heterosexual individuals (Quinn, Schabath, Sanchez, Sutton, & Green, 2015;
US Department of Health Human Services, 2010). This shortage, along with
negative past health care experiences, may help explain the high rates of nondi-
sclosure of sexual orientation to providers found among LGBT individuals. Given
the unique medical concerns and health disparities found in this population,
disclosure of gender identity or sexual orientation may help guide assessment
and treatment considerations. Furthermore, nondisclosure has been associated
with long-term consequences, with one study finding that nondisclosure of sexual
orientation related to poorer psychological wellbeing at 1-year follow-up (Durso &
Meyer, 2013). In general, nondisclosure of sexual orientation to health care
providers has been shown to be more prevalent among bisexual men and
women compared to gay men and lesbians (Durso & Meyer, 2013;Petroll&
Mitchell, 2015). In the transgender population, higher levels of provider nondi-
sclosure have been associated with lower rates of utilization of health services,
especially in rural areas (Whitehead, Shaver, & Stephenson, 2016).
Systemic and cultural factors, including racial, spiritual, political, and
personal variables, often amplify health disparities and access to care issues
within the LGBT community. For example, sexual minority status has been
shown to negatively impact access to health care, particularly if the individual
is a member of multiple marginalized groups (Smith, 2015). This may be
particularly true in Southern U.S. states, a geographic region with more
conservative views on sexual orientation and gender identity, on average,
than other regions (Matthews & Lee, 2014). Regarding health care within the
general population, persons living in this region tend to have more problems
with health care access, with a high uninsured rate and fewer accessible
providers, especially in outlying rural areas (County Health Rankings,
2016). In the state of Georgia specifically, averages of individuals reporting
poor health, number of poor physical and mental health days, and number of
newly diagnosed sexually transmitted infections are higher than national
comparative data (County Health Rankings, 2016). Better health has been
found in Georgias metropolitan areas, potentially due to differences in
education, race, and socioeconomic disparities found in less populated
areas (County Health Rankings, 2016).
Using a narrower lens, many of the counties surrounding the Augusta,
Georgia area are considered rural and/or medically underserved, putting
individuals at risk for experiencing geographically associated health dispa-
rities, such as higher incidence of disease and disability (National Rural
Health Association, 2017). Despite these concerns, in 2015 less than 1% of
Georgia Department of Community Health expenditures were in the areas of
health care access and improvement (Georgia Department of Community
JOURNAL OF HOMOSEXUALITY 3
Health, 2015). Additional social and institutional factors present barriers to
care for the local LGBT community, as evidenced by Augusta, Georgias
extremely low ranking on the Human Rights Campaigns 2016 Municipal
(LGBT) Equality Index; Augusta received a score of 12/100, compared to an
average score of 33 in GA and 56 nationally (Human Rights Campaign
Foundation, 2016).
Health care experiences of LGBT members living in rural and smaller
metropolitan areas may be different than those living in larger urban metro-
politan areas due to limited resources (both LBGT-specific and general
community assistance) and fewer legal protections against discrimination in
housing and employment (Coleman, Irwin, Wilson, & Miller, 2014). Little is
known about the specific health care needs of LGBT groups in these regions,
but a growing body of research offers some insight into the disparities they
encounter. For example, HIV rates among gay and bisexual men in smaller
cities in the South, such as Augusta, Georgia and Jackson, Mississippi, are
almost three times that of the national average of 11% (Rosenberg, Grey,
Sanchez, & Sullivan, 2016). Moreover, a qualitative study of rural mental
health providers identified that individual and institutional LGBT bias was
commonplace in rural LGBT-serving mental health outpatient, inpatient, and
residential services (Willging, Salvador, & Kano, 2006).
Given previous evidence suggesting region-specific health disparities among
LGBT people, as well as the overall continued importance of identifying and
reducing these disparities, the current study surveyed the mental and physical
health experiences and needs of LGBT individuals in a largely rural area of the
Southern United States. Specifically, experiences of LGBT individuals were
assessed within the Central Savannah River Area (CSRA), which consists of 18
counties within Georgia (13 counties) and South Carolina (five counties), includ-
ing Augusta, Georgia, the areas largest city (United States Census Bureau, 2015).
Methods
The current health needs assessment was a collaboration between the
Medical College of Georgia at Augusta University and the Equality Clinic
of Augusta, Inc., an interprofessional, student-run primary care clinic that
serves uninsured or underinsured and low-income LGBT individuals in the
CSRA. The total population of the area is estimated at over 750,000 people,
with much of the region considered to be medically underserved (Georgia
Department of Community Health, 2015; United States Census Bureau,
2015). Additionally, few LGBT-specific resources exist in the CSRA, other
than a few services available in the city of Augusta, GA (see Procedure
section for more specific examples). Although a large number of variables
were collected during the health needs assessment, this article specifically
provides a broad overview of sample demographics, physical health and
4L. M. STEPLEMAN ET AL.
mental health concerns, access to and utilization of health and mental health
services, as well as participant beliefs regarding the greatest needs for the
LGBT community in the CSRA. Furthermore, a specific emphasis was placed
on the in-depth exploration of potential differences in data based on age,
race, gender identity, and sexual orientation. Prior to data collection, this
study was submitted to Augusta Universitys Institutional Review Board and
determined to be exempt from review.
Participants
Participation was voluntary and anonymous. All participants had to be
18 years of age or older. Given the target population, additional eligibility
requirements included residence in a ZIP code of a CSRA county and self-
identification as a member of a sexual orientation and/or gender identity
minority group. A total of 602 responses were recorded. Respondents were
removed from the dataset if they reported an age below 18 years (n= 14),
reported a residential ZIP code outside of the CSRA (n= 49), or submitted
the survey after answering five or less demographic questions (n= 74). Self-
identified heterosexual respondents were also removed from the dataset if
they did not additionally identify as intersex, transgender, or gender non-
conforming, or did not report having transgender or same gender sexual
partners currently or in the past (n= 29). After utilizing these inclusion/
exclusion criteria, a total of 436 eligible surveys remained and were used in
analyses. Comprehensive demographic breakdowns of the final sample are
presented in Table 1 and discussed in detail within the Results section.
Measures
To develop the health needs assessment, researchers reviewed LGBT health
needs assessment tools previously used from numerous geographic areas. The
content of each survey was examined and compared to identify well-constructed
items that best assessed our target content priorities. In addition to extensive
demographics, we prioritized health and mental health concerns, access to and
utilization of physical health services, mental health services, and prevention
services, health behaviors (such as smoking and physical activity), LGBT dis-
closure, stigma, safety, and community affiliation with, as well as opinions
regarding the greatest needs for, the LGBT community in the CSRA. A total
of 86 questions were included in the survey, which was constructed using
appropriate skip logic for questions that may not be applicable to everyone
(i.e., tobacco use behaviors in those who denied tobacco use). Again, given the
copious amount of data collected, this article focuses only on a subset of the total
number of variables. Specifically, to describe our sample and primary health
variables, we included the following measures in the current study.
JOURNAL OF HOMOSEXUALITY 5
Basic demographics
Demographic variables in the current study included gender identity (female,
male, intersex, transgender male, transgender female, genderqueer, or other),
age (numerically entered in years), race (White/Caucasian, Black/African
American, Hispanic, Biracial/Multiracial, American Indian/Alaska Native,
Table 1. Basic demographics.
Characteristic n%
Gender
Male 195 44.8
Female 160 36.8
Transgender male 28 6.4
Transgender female 20 4.6
Genderqueer 19 4.4
Other 11 2.5
Intersex 2 0.5
Age Groups
1836 282 65.1
3756 114 26.3
5776 37 8.5
Race
White/Caucasian 289 67.4
Black/African American 85 20.0
Hispanic 20 4.7
Biracial/Multiracial 16 3.8
American Indian/Alaska Native 8 1.9
Asian 6 1.4
Native Hawaiian/Other Pacific Islander 2 0.5
Other 2 0.5
Ethnicity
Not Hispanic/Latino/Latina 400 92.8
Hispanic/Latino/Latina 31 7.2
Sexual Identity
Gay 167 38.8
Lesbian 109 25.3
Bisexual 58 13.5
Pansexual 36 8.4
Straight/Heterosexual 22 5.1
Other 18 4.2
Queer 13 3.0
Asexual 10 2.3
Questioning 7 1.6
Relationship Status
a
Single 170 34.3
Married 79 16.0
In a serious romantic partnership with one person 67 13.5
Member of a couple living together/domestic partnership 60 12.1
Dating one person 51 10.3
Member of a couple not living together 28 5.7
Other 16 3.2
Dating more than one person 15 3.0
Widowed 7 1.4
Legally separated 2 0.4
Note. Percentages are listed as valid percent.
a
Respondents could choose more than one answer.
6L. M. STEPLEMAN ET AL.
Asian, Native Hawaiian/Other Pacific Islander, or other), ethnicity (yes/no
response to identifying as Hispanic), and sexual orientation (bisexual, gay,
lesbian, pansexual, queer, questioning, straight/heterosexual, or other).
Socioeconomic factors
Additional socioeconomic variables were used, such as level of education
(less than high school, high school diploma or GED, some college, associates
degree, bachelors degree, some graduate/professional school, graduate
degree, or doctoral/professional degree), annual household income (nine
options, starting at up to $9,999and increasing by $5,000 increments
through $100,000 and over), current employment status (participants
could select as many of the 13 options, such as full-time employment, retired,
and unemployed, as were applicable), health insurance status (participants
could select as many of the nine options, such as Medicaid, private health
insurance, and no health insurance, as were applicable), and relationship
status (participants could select as many of the 10 options, such as single,
dating more than one person, and widowed, as were applicable).
Health and mental health
Participants reported previous/current diagnosis with or treatment for 18
different physical and mental health conditions, including obesity, HIV, high
cholesterol, depression, substance use, and suicidal thoughts. Additionally,
three items from the Health-Related Quality of Life self-report 4-item mea-
sure (HRQOL-4) were used to assess the status of individual general, physi-
cal, and mental health (CDC, 2016a). Specifically, participants rated their
general health on a 5-point Likert scale, ranging from excellent to poor,as
well as listed the number of days of poor physical and mental health in the
past 30 days.
Health care participation and experiences
Health care access was assessed using two items from the Behavioral Risk
Factor Surveillance Survey (BRFSS), created by the CDC (2014). Participants
were asked, Do you have someone you think of as your personal doctor or
health care provider?Response options included: Yes, I have one person I
think of as a personal doctor or primary health care provider,”“Yes, I have
more than one person I think of as a personal doctor or primary health care
provider,and No, I do not have anyone I think of as a personal doctor or
primary health care provider.Participants were also asked to rate on a 4-
point scale from never to less than 1 year ago how long ago they received care
from various providers, including medical providers, dental care providers,
and mental health providers.
A variety of health care experiences were assessed using adapted questions
from Lambda LegalsWhen Health Care Isnt Caringsurvey (Lambda
JOURNAL OF HOMOSEXUALITY 7
Legal, 2010) and the Seattle LGBT Commission Report of Needs Assessment
Survey 2010(Boog, Cridland, Villanueva, Juárez-Díaz, & Ballezza, 2011).
The current study used questions from Lambda Legal assessing experiences
with medical providers, including care refusal, refusal to touch or use of
excessive precautions, perceived blame for health status, use of harsh or
abusive language, and physical roughness or abuse. Questions from the
Seattle Needs study included two items assessing poor treatment by a provi-
der due to (1) sexual orientation and/or (2) gender identity, as well as an item
surveying the belief that providers need more education/awareness about
LGBT health needs. Answer choices were yes,”“no,”“not sure,and prefer
not to answer,although not sureand prefer not to answeroptions were
not used in analyses.
Barriers and needs
Participants were asked to select the three most important services needed by
LGBT persons in the CSRA from a list of 13 items, such as mental health
services, public awareness about LGBT issues, and services for LGBT youth.
Items measuring barriers to health care access, services, and opportunities
were measured using the LGBT-adapted 12-item Barriers to Care Scale
(BACS) from its initial development for use in the HIV population
(Adapted by Strength in Numbers Consulting Group from Heckman et al.,
1998). Participants were asked to rate the extent of which each of the 12
items, related to geography/distance, medical and psychological factors, com-
munity stigma, and personal resources, is a problem. Response options
included whether each barrier was a major problem,”“somewhat of a
problem,”“very slight problem,or no problem at all(on a scale of 14,
respectively).
Procedure
Participant recruitment
Participant recruitment took place from February to June of 2016. To max-
imize recruitment of a diverse sample in an area with only a small number of
identified LGBT venues, a variety of recruitment strategies were used, includ-
ing venue-based and snowball sampling methods. For venue-based sampling,
the study team conducted direct outreach to specific local venues (meeting
directly with patrons at local establishments), as well as hanging posters and
distributing postcards at the Equality Clinic of Augusta, Inc., and several
other hospitals and health clinics, local bars and clubs, churches, Web sites,
print and social media sites, community-based organizations, and at com-
munity events, including Augusta Pride. Study participants (people who
completed the health needs assessment on site) and prospective participants
(those provided with postcards to complete the survey at their leisure) were
8L. M. STEPLEMAN ET AL.
given multiple postcards with the request that they distribute the material to
other eligible individuals. For additional social media outreach, a Facebook
page for the survey was also created and shared by the Equality Clinic of
Augusta, Inc., Augusta Pride, and other organizations and individuals.
During the collection period, the page was periodically updated with the
locations and dates of venue sampling events. A link to the survey Web page
was also provided, and individuals were encouraged to participate and share
the link with friends and family on their personal pages.
Health needs assessment administration
The health needs assessment was completed via Qualtrics, a Web-based
survey site, and took an average of 32 minutes to complete. It could be
completed via computer, smartphone, or tablet, the latter two being the
primary means for assessment completion for venue sampling. Tablets
were provided by the study team for onsite participants to facilitate ease of
completion at time of recruitment. For venue sampling, researchers set up a
table that provided information about the health needs assessment, as well as
free offerings, including condoms, candy, and rainbow stickers. After com-
pletion, participants could elect to be linked to a separate survey, where they
could provide their contact information to be entered into a drawing to win a
VIP ticket to a future Augusta Pride or one of four $25 gift cards.
Analyses
All data analyses were performed using SPSS 23 (StataCorp LP). For mea-
sures that included a prefer not to answeroption, these responses were not
included in analyses. In the current dataset, no identifiable patterns of
missing data were identified. Most instruments within the survey were single
item or contained a small number of items. Missing data most commonly
occurred due to participants prematurely discontinuing the survey. Given the
large sample size, listwise deletion was used for missing data.
Frequencies and percentages were used to describe the demographics of
the sample, as well as needs assessment items of interest. To investigate
differences in item response by gender identity, sexual orientation, race/
ethnicity, and age, ttest, analysis of variance (ANOVA), and chi-square
(with Yates Continuity Correction) testing was used. For comparison testing,
these demographics categories were collapsed. For instance, based on the
majority of responses falling within one of these categories, analyses of
gender identity included four groups (cisgender female, cisgender male,
transgender female, and transgender male). Sexual orientation was collapsed
into lesbian, gay, and bisexual, while race/ethnicity was collapsed into White/
Caucasian, Black/African American, and Hispanic/Latino/Latina. To explore
differences across age, the sample was divided into thirds to create distinct
JOURNAL OF HOMOSEXUALITY 9
age groups, with the upper (ages 5776) and lower (ages 1836) thirds being
used for specific comparison purposes.
Results
Basic demographics
As presented in Table 1, most respondents identified as male, 44.8% (n= 195),
followed by female, 36.8% (n= 160). A smaller number of participants identified
as transgender male, transgender female, or genderqueer. Of those who selected
the othercategory (n= 11) and chose to provide their own response, gender-
fluidand agenderwere the most frequent responses. The mean age of survey
respondents was 34.8 years and ranged between 18 and 76 years. Approximately
half of the sample, 50.1% (n= 217), were between the ages of 25 and 44 years.
The majority of respondents were either White, comprising 67.4% of the sample
(n= 287), or Black, 20.0% of the sample (n= 85). In terms of ethnicity, 7.2%
(n= 31) of those surveyed identified as Hispanic/Latino/Latina.
For sexual identity, most respondents reported identifying as gay, 38.8% of
the sample (n= 167), or lesbian, 25.3% of the sample (n=109). As previously
described, the category of straight/heterosexual was included to capture
circumstances such as transgender individuals self-identifying as straight/
heterosexual and individuals whose partners identified as transgender. Only
5.1% of respondents (n= 22) were included in this category. Respondents
could select more than one relationship status to best define their current
relationship situation, with singlecomprising 34.3% (n= 170) of the overall
selections and widowed(n= 7) and legally separated(n= 2) comprising
less than 2%. Of the 16 survey participants who chose other,divorced and
engaged were the most commonly reported responses. A full overview of the
demographics can be found in Table 1.
Socioeconomic factors
Descriptive characteristics of socioeconomic information, including educa-
tion, employment, income, and insurance status, can be found in Table 2.
The sample population was composed largely of highly educated individuals,
with more than 70.0% of respondents having at least some college education.
Approximately 13%14% of respondents indicated that they had earned their
high school diploma/GED (n= 59) or attended vocational school/held an
Associates degree (n= 53). Only about 2% of respondents endorsed not
completing high school (n= 9).
For employment, respondents could choose as many employment cate-
gories as they believed were relevant to their current situation. A large
majority of respondents indicated some type of current employment or
10 L. M. STEPLEMAN ET AL.
student status. Unemployment numbers, including those who were perma-
nently unable to work, were low, comprising less than 10% of overall
responses. Relating to household income, around 40% of respondents
reported earning more than the median household income in the Augusta-
Richmond County metro area of GA, which is around $49,721 (as of 2015;
www.census.gov). Approximately half of the samples yearly income was at or
below $39,999 (n= 170).
Table 2. Socioeconomic characteristics.
Characteristic n%
Education
Less than high school 9 2.2
High school diploma/GED 59 14.1
Some college 130 31.1
Associates degree or vocational education 53 12.7
Bachelors degree 73 17.5
Some graduate/professional school 21 5.0
Graduate degree 50 12
Doctoral/professional degree 23 5.5
Employment Status
a
Full-time employment 216 39.4
Part-time/occasional work/casual employment 99 18.1
Student full or part-time 88 16.1
Self-employed/business owner 33 6.0
Retired 29 5.3
Unemployed 27 4.9
Intern/volunteer 16 2.9
Other 14 2.6
Home duties 13 2.4
Permanently unable to work 13 2.4
Legally separated 2 0.4
Annual Household Income
Up to $9,999 32 9.1
$10,000$14,999 37 10.5
$15,000$19,999 24 6.8
$20,000$29,999 38 10.8
$30,000$39,999 39 11.0
$40,000$49,999 49 13.9
$50,000$74,999 51 14.4
$75,000$99,999 35 9.9
$100,000 and over 48 13.6
Type of Insurance
No insurance 73 19.4
Private health insurance through my or someone elses employer 171 45.4
Private insurance bought on the health exchange 27 7.2
Military insurance (Tricare) 26 6.9
Medicare 20 5.3
VA benefits 18 4.8
Other private insurance not bought on the health exchange, e.g., student health insurance 17 4.5
Medicaid 14 3.7
Some other type of insurance 11 2.9
Note. Percentages are listed as valid percent.
a
Respondents could choose more than one answer.
JOURNAL OF HOMOSEXUALITY 11
The most common response, or approximately 45% of overall responses,
to the type of insurance used for medical needs was private insurance
through the respondents employer or someone elses employer, such as a
spouse, partner, or parent (n= 171). However, following this response, the
next largest group, or approximately 19% of responses, indicated a lack of
insurance (n= 73). Rates of being insured varied significantly based on age,
race, and gender identity, while no significant differences were found based
on sexual orientation.
Younger respondents were more likely to endorse being uninsured than
older respondents, χ
2
(1, N= 271) = 9.23, p= .002, while Black respondents
were significantly less likely to have insurance than White respondents, χ
2
(1,
N= 314) = 4.94, p= .026. No significant differences were found between
Hispanic respondents and Black or White respondents. Transgender women
were significantly more likely to be uninsured compared to cisgender
women, χ
2
(1, N= 158) = 31.40, p< .001), cisgender men, χ
2
(1,
N= 185) = 31.94, p< .001, and transgender men (χ
2
(1, N= 50) = 11.06,
p=.001). No differences in insurance coverage were found between trans-
gender men and cisgender men or women.
Health and mental health
Respondents were asked to best describe their current general health status.
A majority of respondents considered themselves relatively healthy, with the
largest portion of those surveyed describing their current health as very
good(36.9%). Responses of fair(9.2%) and poor(1.8%) health were
least frequently reported. In total, nearly 90% of those surveyed described
their health as good,”“very good,or excellent.ANOVA analysis with
Bonferroni post hoc testing revealed that cisgender women and transgender
men rated their overall health status as worse than cisgender men, F(3,
350) = 6.59, p< .001, and that lesbians rated their overall health as worse
than gay men, F(2, 291) = 3.66, p= .027. No significant differences were
identified within race or age subgroups.
The reported average number of days within the past month of poor
physical health was 4.5. There were no significant differences found in
number of days of poor physical health based on gender identity, race, or
age. However, differences between sexual orientation groups were noted,
with lesbians reporting a significantly higher number of days of poor physical
health (M= 5.27) than gay men (M= 2.81), F(2, 286) = 3.86, p= .02.
Respondents reported an average of 7.8 days of poor mental health within
the past month. Analyses revealed significant findings between genders, F(3,
326) = 10.81, p< .001. Specifically, transgender individuals reported a sig-
nificantly higher number of poor mental health days than cisgender indivi-
duals, with transgender men averaging 15.4 days and transgender women
12 L. M. STEPLEMAN ET AL.
averaging 12.4 days. Finally, older respondents reported significantly fewer
days of poor mental health than younger respondents, with an approximate
5-day mean difference between the youngest and oldest age groups, t
(47.63) = 3.43, p= .001. No differences were found between race subgroups
for poor mental health days.
Tables 3 and 4show the number of participants endorsing diagnosis and/
or treatment of, both historically and/or currently, various physical and
mental health conditions. Approximately 31% of respondents reported obe-
sity or being overweight, which was the most frequently reported physical
health condition (n= 115), while only approximately 4% of respondents
reported hepatitis, which was the least frequent experienced condition
(n= 15). Almost half of the sample reported experiencing depression
(n= 183) and/or anxiety (n= 179), while less than 10% of the sample
reported substance userelated conditions, including alcohol abuse/addiction
(n= 33) and drug abuse/addiction (n= 35).
For both physical and mental health conditions, chi-square analyses
revealed differences within age, gender identity, sexual orientation, and racial
subgroups. Compared to older respondents, younger respondents were more
likely to report a history of asthma, χ
2
(1, N= 261) = 4.44, p= .035.
Conversely, compared to younger respondents, older respondents were
more likely to report a history of diabetes, χ
2
(1, N= 254) = 12.98,
Table 3. Reported physical health concerns.
Concern n%
Obesity or overweight 115 31.4
Hypertension 80 22.0
Asthma 74 20.7
High cholesterol 71 19.6
HIV/AIDS 32 9.0
Diabetes 28 7.9
Heart disease 24 6.8
Cancer 20 5.6
Hepatitis 15 4.2
Note. Percentages listed are valid percentages; respondents could choose as many as applied.
Table 4. Reported mental health and substance use concerns.
Concern n%
Depression 183 49.2
Anxiety 179 48.1
Suicidal thoughts 105 29.2
Tobacco use 99 27.3
ADHD 79 21.9
Suicide attempts 66 18.5
Bipolar disorder 53 14.6
Drug abuse/addiction 35 9.8
Alcohol abuse/addiction 33 9.2
Note. Percentages listed are valid percentages; respondents could choose as many as applied.
JOURNAL OF HOMOSEXUALITY 13
p< .001, cardiovascular disease, χ
2
(1, N= 257) = 56.29, p< .001, hyperli-
pidemia, χ
2
(1, N= 262) = 71.70, p< .001, hypertension, χ
2
(1,
N= 266) = 59.54, p< .001, obesity, χ
2
(1, N= 264) = 6.73, p= .009, HIV/
AIDS, χ
2
(1, N= 260) = 9.24, p= .002, hepatitis, χ
2
(1, N= 258) = 4.87,
p= .027, and cancer, χ
2
(1, N= 261) = 4.03, p= .045.
Compared to cisgender men, cisgender women reported experiencing
more anxiety, χ
2
(1, N= 292) = 5.88, p= .015, depression, χ
2
(1,
N= 293) = 8.64, p= .003, suicidal ideation, χ
2
(1, N= 282) = 8.42,
p= .004, and obesity, χ
2
(1, N= 288) = 24.81, p< .001. Additionally,
cisgender women reported higher rates of obesity than transgender women,
χ
2
(1, N= 151) = 5.55, p= .019, and transgender men, χ
2
(1, N= 159) = 4.99,
p= .025, while cisgender men reported significantly higher rates of HIV/
AIDS than cisgender women, χ
2
(1, N= 278) = 15.99, p< .001, and
transgender men, χ
2
(1, N= 182) = 5.52, p= .019. Transgender men reported
higher rates of suicidal ideation, χ
2
(1, N= 184) = 5.65, p= .018, suicide
attempts, χ
2
(1, N= 180) = 4.93, p= .026, and depression, χ
2
(1,
N= 189) = 5.75, p= .017, than cisgender men. Additionally, transgender
women endorsed higher rates of suicidal ideation, χ
2
(1, N= 177) = 11.55,
p= .001, suicide attempts, χ
2
(1, N= 174) = 20.06, p< .001, and depression,
χ
2
(1, N= 181) = 5.97, p= .015, than cisgender men, as well as higher rates of
suicide attempts than cisgender women, χ
2
(1, N= 146) = 8.77, p= .003.
Lesbians reported significantly higher amounts of obesity compared to gay
men, χ
2
(1, N= 233) = 15.25, p< .001, and bisexual participants, χ
2
(1,
N= 137) = 4.07, p= .044. Compared to gay men, lesbians, χ
2
(1,
N= 228) = 6.08, p= .014, and bisexual individuals, χ
2
(1, N= 187) = 5.11,
p= .024, endorsed significantly higher rates of suicidal ideation. Gay men
endorsed significantly higher rates of HIV than lesbians, χ
2
(1,
N= 226) = 12.22, p< .001.
Caucasian individuals were more significantly more likely to endorse
hyperlipidemia, χ
2
(1, N= 304) = 5.84, p= .016, depression, χ
2
(1,
N= 313) = 9.02, p= .003, anxiety, χ
2
(1, N= 314) = 8.15, p= .004, and
tobacco use, χ
2
(1, N= 303) = 6.98, p= .008, compared to Black respondents.
Conversely, Black respondents were more likely to report a history of asthma
compared to both Hispanic respondents, χ
2
(1, N= 89) = 5.26, p= .022, and
Caucasian respondents, χ
2
(1, N= 302) = 4.92, p= .027. Additionally, Black
respondents endorsed a history of HIV/AIDS at a higher rate than Caucasian
respondents, χ
2
(1, N= 300) = 13.89, p< .001. Hispanic individuals reported
higher rates of obesity compared to both Caucasian respondents, χ
2
(1,
N= 269) = 4.07, p= .044, and Black respondents, χ
2
(1, N= 90) = 7.98,
p= .005. Furthermore, Hispanic individuals reported higher rates of hyperli-
pidemia, χ
2
(1, N= 86) = 4.45, p= .035, and anxiety, χ
2
(1, N= 89) = 4.11,
p= .043, compared to Black respondents.
14 L. M. STEPLEMAN ET AL.
Health care participation and experiences
Survey participants were asked if they had a health care provider that they
considered their primary care provider (PCP), including a physician, doctor,
physician assistant, and/or nurse practitioner. Nearly 50% of the sample
(n= 195) endorsed having a PCP, with approximately 15% (n= 57) reporting
more than one PCP. Over one third of our population denied having a
primary care provider (n= 140). Individuals in the 1836 age group reported
not having a PCP more frequently than individuals in the older age group, χ
2
(1, N= 287) = 20.63, p< .001. Transgender women denied having a PCP at a
significantly higher rate than both cisgender women, χ
2
(1, N= 163) = 8.35,
p= .004, and cisgender men, χ
2
(1, N= 192) = 9.33, p= .002. Additionally,
transgender men denied having a PCP at a higher rate than both cisgender
women, χ
2
(1, N= 170) = 7.75, p= .005, and cisgender men, χ
2
(1,
N= 199) = 8.80, p= .003. No significant differences in endorsement of
having a PCP were found among race or sexual orientation subgroups.
Table 5 includes responses to a survey item assessing the most recent visit
to a health care provider, including PCP, dentist, and mental health provider.
Most respondents had seen a PCP or a dental care provider less than 1 year
ago. However, around 8% of our population has never seen either a PCP or
dental care provider. The length of time from seeing a mental health provider
was found to be significantly longer for Black respondents than for Caucasian
respondents, F(2, 338) = 6.78, p< .001. Individuals in the 1836 year age
group reported a longer span of time since seeing a dental care provider than
the 5776 year age group, t(96.60) = 6.21, p< .001. The length of time from
last visit with a mental health care provider was significantly longer for
transgender women compared to cisgender males, F(3, 338) = 3.18,
p= .024. Additionally, the length of time from last visit with a dental care
provider was significantly longer for transgender women compared to cis-
gender males, F(3, 342) = 2.72, p= .045. No differences were noted within
sexual orientation subgroups.
Survey respondents were also asked about health care experiences, with
results shown in Table 6. Nearly half of all survey respondents (n= 177)
reported that they believed that their health care provider needed more
education/awareness about the health care needs of the LGBT population.
Table 5. Time since last visit based on type of health care provider.
NP, PA, and/or physician/doctor Dental care provider Mental health provider
Time since last visit n%n%n%
Not at all/Never 29 7.6 31 8.1 145 38.6
Greater than 2 years ago 46 10.6 95 21.8 103 23.6
Between 12 years ago 47 10.8 56 12.8 32 7.3
Less than 1 year ago 260 59.6 199 45.6 96 22.0
Note. NP = nurse practitioner; PA = physician assistant. Percentages listed are valid percentages.
JOURNAL OF HOMOSEXUALITY 15
Other frequently endorsed experiences included 18% of respondents report-
ing being blamed for their own health status (n= 66) and approximately 13%
of respondents reporting both harsh or abusive language being used toward
them (n= 48) and being refused health care (n= 46).
When looking across subgroups, several significant differences in health care
experiences were found based on race, age, and gender identity, although no
differences were found between sexual orientation subgroups. The only differ-
ence noted between the younger and older age groups involved believing
providers need more LGBT-specific education, with the 1836-year age group
endorsing this item at a higher ratethan individuals in the 5776 age range, χ
2
(1,
N= 219) = 4.05, p= .044. Regarding race, Black respondents believed providers
needed more education/awareness about LGBT health needs significantly more
than Caucasian respondents, χ
2
(1, N= 257) = 7.89, p= .005. Both Black, χ
2
(1,
N=85)=3.96,p= .047, and Caucasian, χ
2
(1, N= 272) = 6.07, p=.014,
respondents reported significantly higher rates of being blamed for their health
status than Hispanic individuals.
Across gender identity, being refused health care was more frequently
reported by transgender women than cisgender women, χ
2
(1,
N= 138) = 4.67, p= .031, and cisgender men, χ
2
(1, N= 170) = 9.95, p=.002.
Additionally, health care refusal was reported more frequently by transgender
men than cisgender men, χ
2
(1, N= 176) = 8.75, p= .003. Endorsement of
providers needing more education/awareness about LGBT health needs was
more frequent among transgender women, compared to cisgender women, χ
2
(1, N= 121) = 3.87, p= .049, and cisgender men, χ
2
(1, N= 151) = 4.99, p= .025,
as well as among transgender men, compared to cisgender women, χ
2
(1,
N=130)=7.01,p=.008, and cisgender men, χ
2
(1, N=160)=8.88,p=.003.
Reports of health care professionals refusing to touch or using excessive precau-
tions was more frequent among transgender women compared to cisgender
women, χ
2
(1, N= 151) = 17.63, p= .000, and cisgender men, χ
2
(1,
N= 158) = 11.91, p= .001, as well as among transgender men compared to
Table 6. Number of respondents who reported mistreatment by health care professionals.
Reported type of mistreatment n%
Ever refused health care 46 12.6
Treated poorly by a provider or refused health care in the past five years because of sexual
orientation
42 11.6
Treated poorly by a provider or refused health care in the past five years because of gender
identity
29 8.0
Provider needs more education/awareness about the health care needs of the LGBT
population
177 48.9
Health care professionals have refused to touch me or used excessive precautions 36 9.7
Health care professionals have used harsh or abusive language toward me 48 13.1
Health care professionals have blamed me for my health status 66 18.0
Health care professionals have been physically rough or abusive toward me 14 3.8
Note. Percentages listed are valid percentages.
16 L. M. STEPLEMAN ET AL.
cisgender women, χ
2
(1, N= 183) = 12.35, p=.000,andcisgendermen,χ
2
(1,
N= 190) = 7.60, p= .006. Higher rates of health care professionals using harsh or
abusive language was found among transgender women, compared to cisgender
women, χ
2
(1, N= 149) = 9.31, p= .002, and cisgender men, χ
2
(1,
N= 181) = 10.94, p= .001, as well as among transgender men compared to
cisgender women, χ
2
(1, N= 157) = 9.57, p= .002, and cisgender men, χ
2
(1,
N= 189) = 11.41, p= .001. Finally, transgender men reported being blamed for
their health status significantly more than cisgender men, χ
2
(1, N= 190) = 9.76,
p=.002.
Barriers and needs
Respondents were asked to rate the extent to which each of the listed issues,
as seen in Table 7, were a problem in their life. Respondents selected whether
each factor was a major problem,”“somewhat a problem,”“very slight
problem,or not at all a problem.Results were consolidated into either
reported as a problem,which combined the responses of a major problem,
somewhat a problem, and very slight problem, or not reported as a pro-
blem,which exclusively included the responses of not at all a problem. The
highest reported problem was community residentsstigma against LGBT
people,with 65.3% (n= 247) of our population selecting that this issue was a
problem in their lives to some extent. The next most prevalent problems were
lack of supportive and understanding work environments,with 63.3%
(n= 240) reporting this as a problem, and lack of knowledge about LGBT
people among residents in the community,with 61.5% (n= 246) reporting
this as a problem. The issues least reported as problematic were medical
personnel (e.g., physicians, nurses) who discriminate against LGBT people
when providing direct care,reported as a problem by 31.4% of our popula-
tion (n= 119), long distances to medical facilities and personnel,reported
by 21.0% (n= 80), and lack of transportation to access services,reported by
Table 7. Number of respondents who report each factor as a problem.
Specific factor reported as a problem n%
Community residentsstigma against LGBT people 247 65.3
Lack of supportive and understanding work environments for LGBT people 240 63.3
Level of knowledge about LGBT people among residents in the community 246 61.5
Lack of psychological support groups for LGBT people 211 55.8
Lack of adequately trained and competent LGBT health care professionals 206 54.1
Lack of employment opportunities for LGBT people 196 52.1
Personal financial resources 185 48.9
Shortage of mental health providers who can address issues 182 48.1
Lack of adequate and affordable housing 142 38.2
Medical direct care discrimination against LGBT people 119 31.4
Long distances to medical facilities and personnel 80 21.0
Lack of transportation to access services 74 19.5
Note. Percentages listed are valid percentages.
JOURNAL OF HOMOSEXUALITY 17
19.5% (n= 74) of our population. Of the four BACS subscales, the most
highly endorsed barrier to care was personal resources(71.8%; n= 265),
followed by community stigma(68.6%; n= 258), medical and psycholo-
gicalconcerns (66.2%; n= 247), and geography/distance(28%; n= 106).
Respondents were also asked to pick the three most important services
needed by LGBTQ people in the CSRA, if funding were available. A sum-
mary of the most commonly reported service needs is provided in Table 8.
The needed service most commonly reported was mental health services,
with 216 people (49.5% of respondents) selecting this item. Services for
LGBT youth was reported as the second most needed service, with 25% of
respondents (n= 109) selecting this need, followed closely by physical health
services for LGBT people, selected by 24.8% of respondents (n= 108). The
least commonly selected services were LGBT legal services (10.1%, n= 44),
LGBT advocacy at the state legislature (10.1%, n= 44), and domestic violence
services (4.1%, n= 18).
Discussion
The data reveal the health needs, disparities, and experiences of a population
that is diverse in terms of age, race, sexual orientation, and gender identity.
Overall, findings indicate that health problems and insurance coverage, as
well as health care participation and experiences, were not uniformly
reported among these demographic groups. However, across all groups,
almost 50% of all participants agreed that their providers need more educa-
tion about the health care needs of the LGBT population, aligning with the
identified shortage of LGBT-competent providers (U.S. Department of
Health Human Services, 2010). Additionally, approximately 36% of total
respondents denied having a primary care provider (PCP) or personal care
Table 8. Number of respondents who selected each service as a crucial need.
Service n%
Mental health services 216 49.5
Services for LGBT youth 109 25.0
Physical health services 108 24.8
AIDS and HIV services 105 24.1
Sexual health education/STD prevention 96 22.0
LGBT community centers/spaces 84 19.3
Substance abuse services 72 16.5
Family counseling 63 14.4
Public awareness about LGBT issues 61 14.0
Social activities/recreation 49 11.2
LGBT legal services 44 10.1
LGBT advocacy at the state legislature 44 10.1
Domestic violence services 18 4.1
Note. Crucial = selected the service as one of the three most needed services. Percentages listed are valid
percentages.
18 L. M. STEPLEMAN ET AL.
provider, compared to an estimated national average of 10%13% among the
general population (Saloner, Polsky, Friedman, & Rhodes, 2015).
Provider competency concerns among LGBT individuals can ultimately
interfere with access to care, or the timely use of personal health services to
achieve the best health outcomes(Institute of Medicine, 1993). Andersons
Behavioral Model of Access to Medical Care (1995) has been used extensively
to assess factors that influence utilization and access to care among diverse
populations (Jaffee, Shires, & Stroumsa, 2016). Andersons model (1995)
includes three main components (environment, population characteristics,
and health behaviors) that interact to impact health status outcome factors,
including perceived health status, medically evaluated health status, and
consumer satisfaction. Specifically, the environment factor is composed of
two systematic factors that directly impact both population characteristics, as
well as overall outcome variables: (1) the health care system, or the current
national health policy; and (2) the external environment, including physical,
political, and economic considerations. Within the population characteristics
factor, predisposing characteristics (i.e., age, race, socioeconomic status),
enabling resources (i.e., employment, income, insurance), and need (i.e.,
the belief that medical care is needed) interact in a linear manner to influence
outcome variables, both directly and indirectly through health behaviors.
Health behaviors include personal health practices (i.e., diet, exercise, self-
care) and actual use of health services, which interact to impact both out-
come and population characteristics.
Past research has found that predisposing characteristics, such as age, race,
and gender, can have differential impacts on health care utilization and
health outcomes (Jaffee et al., 2016). Discrimination in health care settings
is particularly prevalent among the transgender community (Jaffee et al.,
2016). Findings from the current study highlight a potential relationship
among transgender individuals between discriminatory health system envir-
onment factors, enabling resources, and use of health services, consistent
with Andersons model (1995). Specifically, results indicated that transgender
individuals experience higher rates of certain health conditions, such as
transgender men experiencing worse overall health compared to cisgender
men and transgender persons experiencing more mental health concerns
compared to cisgender individuals. Despite these concerns, transgender
individuals may be less likely to access consistent care, as evidenced by
lower rates of having a regular health care provider, compared to cisgender
LGB counterparts. While lack of insurance may be a factor for decreased use
of health services among transgender women, significant differences in
insurance were not found among transgender men. However, both transgen-
der men and women reported more systematic issues with health care, such
as provider refusal to touch and use of harsh or abusive language. These
systematic factors may impact access to care, utilization of care, and health
JOURNAL OF HOMOSEXUALITY 19
status for transgender individuals. These findings align with a previous study
that identified that 30.8% of transgender participants delayed care due to
discrimination, with those who had to educate their providers about care
being 4 times more likely to delay care (Jaffee et al., 2016).
Additionally, health system environment and related factors, such as
perceived competence of providers, may differentially impact certain indivi-
duals within the LGBT community. For instance, findings from the current
study indicated that younger participants reported lower rates of insurance,
an important enabling resource, fewer medical conditions that would warrant
need for health care, and less frequent use of services. Aside from these
population characteristics, younger individuals more frequently endorsed
believing that health providers need more LGBT-specific education, a sys-
tematic health environment factor that could further limit access to care for
younger LGBT age groups, even for preventative purposes. Similarly, evi-
dence from the current study suggests that systematic factors disproportion-
ally affect racial minority LGBT individuals. For instance, compared to White
participants, Black participants were more likely to endorse a belief that
providers need more education/awareness of LGBT health needs (a system-
related environment factor), less likely to have insurance (an enabling
resource), and more likely to report a diagnosis of HIV (a health outcome).
In addition to providing supportive evidence to Andersons model, certain
results within the sexual orientation demographic supported other previous
research findings. Specifically, lesbians reported poorer physical health than
gay men, which also may be related to the higher rates of obesity reported by
lesbians, compared to gay men and bisexual individuals. These findings align
with previous research suggesting that lesbian and bisexual women have
higher rates certain health conditions, such as obesity and asthma
(Cochran & Mays, 2007; Dilley et al., 2010; Valanis et al., 2000).
Interestingly, lesbians showed higher rates of reported suicidal ideation
than gay men or bisexual individuals. While sexual minority individuals
have been found to have increased suicidality risk, past research has sug-
gested that gay and bisexual men are at particular risk for lifetime suicide
attempts (King et al., 2008).
In addition to these within-group differences, certain between-group find-
ings were also noteworthy. For instance, cisgender women and transgender
men (compared to cisgender men) and lesbians (compared to gay men) were
identified on several indicators as having poorer perceived physical and
mental health. Biological sex-based factors and early experiences related to
the natal female sex may help explain the poorer health factors found among
these subgroups. Cisgender women and transgender men generally share the
same assigned biological sex, usually based on natal sexual anatomy, chro-
mosomes, and endogenous hormones (with the exception of intersex indivi-
duals). Additionally, most adult transgender individuals spent their
20 L. M. STEPLEMAN ET AL.
childhood and often much of their adolescence living in their sex assigned at
birth (Grant et al., 2011). Research has suggested that differences in health
perceptions begin to emerge during adolescence between genders (Vingilis,
Wade, & Seeley, 2002), with females reporting more physical and psycholo-
gical concerns (Piccinelli & Wilkinson, 2000) that persist well into adulthood,
possibly even after gender-affirming processes.
Additionally, the survey identified important needs for LGBT people in the
Southeastern U.S. Specifically, respondents reported their highest needs to be
mental health, youth, and physical health services, respectively. The survey
also illuminated commonly experienced problems for LGBT people in this
region, including community stigma, lack of a supportive work environment,
and lack of knowledge in the community. These responses demonstrated an
overall perception of lack of knowledge by community members, work
environments, and health providers among this regions LGBT members.
Lack of confidence in community members and providers could result in
health disparities and unmet healthcare needs. Furthermore, previous
research has emphasized the importance of a caring, competent, welcoming,
and confidential approach to health care for LGBT individuals, which
involves focusing on both the environment and the providers (McClain,
Hawkins, & Yehia, 2016). The findings lend further support to the need for
LGBT-affirmative approaches to care, which may help individuals cope with
stigma, minority stress, and related health disparities (Alessi, 2014).
There are a number of limitations to this health needs assessment that
should be acknowledged. First, although we recruited from a large number of
venues, the majority of respondents completed the survey through LGBTQ
or LGBTQ-friendly (i.e., a Unitarian Universalist Church) venues. Hence, we
likely have an overrepresentation of people who publicly identify in at least
some environment as LGBTQ and may therefore have more access to sup-
port from other LGBTQ individuals, which can impact health and mental
health. Similarly, most of the data collected were from individuals residing
within Augusta, Georgia and the counties immediately surrounding them,
such that our most rural, isolated individuals are underrepresented. During
the recruitment phase, we made adjustments in our selection of venues to try
to increase the population of African Americans (who are still underrepre-
sented related to the region) and transgender and gender diverse individuals.
Despite strategic sampling, some of our comparative analyses between groups
were limited due to small sample sizes within some groups. Another limita-
tion is that our decision to do an LGBTQ-specific health needs assessment
limits our ability to make comparisons between the heterosexual cisgender
population and our sample. Still, a significant strength was our sizable and
highly diverse sample overall from a unique region of the country that
receives little attention with regard to their health care needs as LGBTQ
individuals. Another strength was the large number of variables that we
JOURNAL OF HOMOSEXUALITY 21
collected, such that we can look at the community from a number of
different perspectives. The length of the survey also likely contributed to
incomplete data for some individuals.
Conclusion
This is the first LGBTQ health needs assessment of the CSRA region. We believe
it can serve as a model for other small communities to collect similar data. On a
community level, work such as this is critical to shaping where resources are
allocated and how needs are prioritized. Having such detailed data, which is
often not available even when LGBTQ survey items are included in national
surveys, also allows a community to respond to requests for applications that can
bring in resources for high need projects and educate communities to improve
the health and wellness of the LGBTQ population. Furthermore, this study lends
support to the relationship between systematic factors, population characteris-
tics, health behaviors, and health outcomes and access to care. Specifically,
results highlight the importance of necessary systematic changes, within com-
munities and healthcare institutions, required to assure adequate care is pro-
vided to LGBT individuals with various intersecting minority statuses.
Funding
This work was supported by the Arnold P Gold Foundation.
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... Participants considered the physicians ignorant and inexperienced in dealing with LGBT health issues.(203) Exploring healthcare experiences of four hundred and thirty six LGBT clients using primary care services within rural communities of southern states in the USA revealed that transmen and transwomen were more likely to report instances of abuse and disrespect from healthcare professionals compared to the cisgender counterparts.(204) The acts of discrimination were mainly harsh abusive words, being blamed for the health problem and refusal of care. ...
... The acts of discrimination were mainly harsh abusive words, being blamed for the health problem and refusal of care. Overall close to a third reported negative experiences, with participants expressing the opinion that healthcare professionals require more education on LGBT health issues.(204) An online study among four hundred and thirty eight LGBT people living in New Jersey, USA reported that a vast majority did not use healthcare services on a regular basis.(205) ...
... Closely related, evidence in Goldenberg et al. (2020) indicates that transgender individuals living in states with more protective legislation for transgender people around health insurance coverage and anti-discrimination had a lower odds of avoiding health care. More broadly, several studies based on different samples of LGBT people have found that lack of health insurance poses a major barrier in seeking healthcare (e.g., Qureshi et al., 2018;Stepleman et al., 2019). Our causal estimates bolster the arguments in these previous studies regarding the importance of health insurance coverage for improving the mental and physical health of transgender individuals and promoting overall health equity. ...
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... trans individuals, 19 and trans individuals living in the US South are less likely to self-disclose their gender identity. 17 This delays the seeking of necessary health services and leads to worse health outcomes. 20 In 2015, a group of physicians and public health experts affiliated with an urban safety-net hospital in Atlanta, Georgia, began working to provide high-quality trans health care by creating a multidisciplinary clinic (the Gender Center) dedicated to providing comprehensive care for trans patients. ...
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... Further, the community from which our sample was drawn had a trans-specific health care group and a range of available providers who were competent in LGBTQ care if they needed to leave a discriminatory, hostile, or ignorant provider. Previous studies have demonstrated these issues in particular are common for trans people and contribute to delaying or forgoing care (Glick et al., 2018;Jaffee, Shires & Stroumsa, 2016;Kosenko, Rintamaki, Raney, & Maness, 2013), including trans individuals in a geographically similar area (Stepleman et al., 2018). By using the Resilience Activation Framework (Abramson et al., 2015) to map out the resilience attributes of TG/GNB within a specific community, we also determined where health programs and services can be targeted to build resilience. ...
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Background: The transgender community experiences health care discrimination and approximately 1 in 4 transgender people were denied equal treatment in health care settings. Discrimination is one of the many factors significantly associated with health care utilization and delayed care. Objectives: We assessed factors associated with delayed medical care due to discrimination among transgender patients, and evaluated the relationship between perceived provider knowledge and delayed care using Anderson's behavioral model of health services utilization. Research design: Multivariable logistic regression analysis was used to test whether predisposing, enabling, and health system factors were associated with delaying needed care for transgender women and transgender men. Subjects: A sample of 3486 transgender participants who took part in the National Transgender Discrimination Survey in 2008 and 2009. Measures: Predisposing, enabling, and health system environment factors, and delayed needed health care. Results: Overall, 30.8% of transgender participants delayed or did not seek needed health care due to discrimination. Respondents who had to teach health care providers about transgender people were 4 times more likely to delay needed health care due to discrimination. Conclusions: Transgender patients who need to teach their providers about transgender people are significantly more likely to postpone or not seek needed care. Systemic changes in provider education and training, along with health care system adaptations to ensure appropriate, safe, and respectful care, are necessary to close the knowledge and treatment gaps and prevent delayed care with its ensuing long-term health implications.
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Purpose: Gay and bisexual men (GBM) have poorer health outcomes than the general population. Improved health outcomes will require that GBM have access to healthcare and that healthcare providers are aware of their sexual behaviors. This study sought to examine factors associated with having health insurance and disclosure of same-sex sexual behaviors to primary care providers (PCPs) among GBM in primary same-sex relationships. Methods: We conducted an online survey of a national sample of 722 men in same-sex couples living in the United States. Logistic regression and multinomial regression models were conducted to assess whether characteristic differences existed between men who did and did not have health insurance, and between men who did and did not report that their PCP knew about their same-sex sexual activity. Results: Our national sample of same-sex partnered men identified themselves predominantly as gay and white, and most reported having an income and health insurance. Having health insurance and disclosing sexual behavior to PCPs was associated with increasing age, higher education, and higher income levels. Insurance was less prevalent among nonwhite participants and those living in the south and midwest United States. Disclosure of sexual behavior was more common in urban respondents and in the western United States. In 25% of couples, one partner was insured, while the other was not. Conclusions: Having health insurance and disclosing one's sexual behavior to PCPs was suboptimal overall and occurred in patterns likely to exacerbate health disparities among those GBM already more heavily burdened with poorer health outcomes. These factors need to be considered by PCPs and health policymakers to improve the health of GBM. Patient- and provider-targeted interventions could also improve the health outcomes of GBM.
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Health outcomes are affected by patient, provider, and environmental factors. Previous studies have evaluated patient-level factors; few focusing on environment. Safe clinical spaces are important for lesbian, gay, bisexual, and transgender (LGBT) communities. This study evaluates current models of LGBT healthcare delivery, identifies strengths and weaknesses, and makes recommendations for LGBT spaces. Models are divided into LGBT-specific and LGBT-embedded care delivery. Advantages to both models exist and they provide LGBT patients different options of healthcare. Yet, certain commonalities must be met: a clean and confidential system. Once met, LGBT-competent environments and providers can advocate for appropriate care for LGBT communities, creating environments where they would want to seek care.
Article
Design: Analysis of data from 93311 participants in the Women’s Health Initiative (WHI) study of health in postmenopausal women, comparing characteristics of 5 groups: heterosexuals, bisexuals, lifetime lesbians, adult lesbians, and those who never had sex as an adult. Setting: Subjects were recruited at 40 WHI study centers nationwide representing a range of geographic and ethnic diversity. Participants: Postmenopausal women aged 50 to 79 years who met WHI eligibility criteria, signed an informed consent to participate in the WHI clinical trial(s) or observational study, and responded to the baseline questions on sexual orientation. Main Outcome Measures: Demographic characteristics, psychosocial risk factors, recency of screening tests, and other health-related behaviors as assessed on the WHI baseline questionnaire. Results: Although of higher socioeconomic status than the heterosexuals, the lesbian and bisexual women more often used alcohol and cigarettes, exhibited other risk factors for reproductive cancers and cardiovascular disease, and scored lower on measures of mental health and social support. Notable is the 35% of lesbians and 81% of bisexual women who have been pregnant. Women reporting that they never had sex as an adult had lower rates of Papanicolaou screening and hormone replacement therapy use than other groups. Conclusions: This sample of older lesbian and bisexual women from WHI shows many of the same health behaviors, demographic, and psychosocial risk factors reported in the literature for their younger counterparts, despite their higher socioeconomic status and access to health care. The lower rates of recommended screening services and higher prevalence of obesity, smoking, alcohol use, and lower intake of fruit and vegetables among these women compared with heterosexual women indicate unmet needs that require effective interactions between care providers and nonheterosexual women. Arch Fam Med. 2000;9:843-853