Race and Ethnicity
Communities of color experience many of the same problems preventing equitable access to health care among SGM people, including insufficient resources, discrimination, and lack of cultural competence among providers and staff.18; 19 These experiences, as well as historical medical mistreatment, abuses, and structural racism, may contribute to distrust of both medical and behavioral health professionals. Thus, issues of access for SGM people of color can be particularly challenging, worsened by the possibility of facing racism from fellow SGM people and discrimination (e.g., homophobia, biphobia, transphobia, interphobia) from members of their own racial and ethnic communities, as well as providers and staff in primary care.20; 21 Fully supporting SGM people of color requires providers and staff to know about a patient’s multiple identities (in this case race/ethnicity, gender identity, and sexual orientation), and how they may be impacting their health and well-being.20
People with Disabilities
An estimated 3 to 5 million SGM people in the U.S. are now living with disabilities.22 In fact, SGM people are more likely to have a disability than heterosexual and cisgender people. For example, disability rates among bisexual women, lesbians, and bisexual men are higher than the general population with 36.1%, 35.5%, and 40.1% prevalence rates, respectively,23 and transgender people are at disproportionate risk.24; 25 In addition, SGM people with disabilities are more likely than their heterosexual and cisgender counterparts to be unemployed, are overrepresented in the criminal justice system, and grapple with more mental health disparities owing to their exposure to multiple intersecting systems of oppression.26-28 As with other areas of intersectionality, SGM people with disabilities face numerous barriers to getting their health-related needs met. For instance, a lack of resources among provider agencies hampers their capacity to make their services accessible to people with visual or hearing impairments. For this reason, SGM people often struggle with finding services that are both accessible and supportive of their sexual orientation or gender identity. Such challenges are magnified for SGM people with disabilities in rural areas with sparse resources. Transgender people who have disabilities are especially likely to experience discrimination when trying to get health and social services, above the levels of discrimination that nondisabled transgender people and cisgender people with disabilities face.29
Religion and Culture
Religion and spirituality are important cultural influences in the lives of many SGM patients.30 Based on their religious and/or cultural backgrounds, SGM individuals, like other patients, may have perspectives on the causes of and appropriate treatment for medical and behavioral health issues that differ from mainstream Western medicine.31 Care should be taken to explore the values that patients hold regarding health and health care to assure that diagnostic and treatment options respect and reflect these values. These differences may extend to determinations about the appropriateness of including family members in healthcare decisions, using herbal or alternative medicines that may affect allopathic treatments, addressing patient values regarding prevention and diet or fears regarding certain types of medical interventions. While some SGM persons draw great strength from spirituality, others have been harmed by the anti-SGM stances of religious groups.32 Such experiences may inhibit SGM patient expression, a situation that can lead to feelings of distress and isolation. Furthermore, SGM young adults raised religiously may experience conflict and suicidal thoughts. Leaving one’s religion has also been associated with increased suicidal thoughts.31; 33 Providers can support SGM persons facing such tensions by ensuring that they ask relevant questions to understand their religious and spiritual affiliations and how they may affect their health and well-being. Finally, remember that SGM patients’ religious and spiritual beliefs reflect the full range of views found in heterosexual and cisgender populations. SGM patients may experience discrimination for their beliefs based on Islamophobia, anti-Semitism, and other forms of religion-based prejudice. This experience can complicate their ability to access care and social support, thereby contributing to minority stress and decreased health and well-being. Even when patients’ religious and spiritual beliefs appear incongruent with their sexual orientation or gender identity, it is important to respect these beliefs and the people holding them.
Small Towns and Rural Communities
Like other individuals in small towns and rural areas, SGM people may have limited healthcare options.12; 34 Furthermore, religiously affiliated healthcare providers are sometimes the only providers in rural areas and may be allowed to legally discriminate against SGM patients based on religious exemption laws.35 Patients in urban areas can generally explore multiple options for care. Yet rural SGM patients are particularly disadvantaged if a clinic does not offer a specific service, is not a good fit, or cannot provide SGM-competent care.12 This matter can be pressing when transgender patients seek gender-affirming care, such as hormone therapy, and are turned away and forced to travel great distances to receive appropriate care.36 Another factor is socioeconomic status, given that SGM people in rural areas have much higher rates of poverty than those in urban areas.37
Socioeconomic Status
In general, SGM people are more likely to live in poverty than non-SGM individuals, with 21.6% and 15.7% prevalence rates, respectively. Moreover, transgender adults are more likely to be living in poverty (29.4%), while cisgender gay men are the least likely to be in this situation (12.1%).37 Race and ethnicity and other dimensions of identity, such as having a disability, increases the likelihood that poverty will impact an SGM person. Employment discrimination can contribute to economic insecurity among SGM people. Being unemployed and economically unstable are notable contributors to health disparities that also influence the higher rates of uninsurance found in the SGM population, further exacerbating the challenges implicated in accessing health care.38; 39 There are fewer uninsured SGM people in the U.S. since the passage of the Patient Protection and Affordable Care Act of 2010. However, insurance disparities remain among SGM people between the ages of 26-34, SGM people identifying as female, those with unmarried partners, and those living in the states that did not accept the Medicaid expansion.40
Homelessness
Among adults experiencing homelessness, a more significant percentage of transgender and gender-diverse people are unsheltered.41 A higher percentage of SGM people who are unsheltered also have experiences of knife and gun violence.42 Additionally, safety and gender-affirming support systems remain scarce for transgender and gender-diverse adults experiencing homelessness.43 A sizeable number of young people experiencing homelessness identify as SGM, and most SGM youth report family rejection as the reason for being homeless.44 SGM youth experiencing homelessness also have higher rates of victimization, substance use, and mental health concerns compared to their heterosexual and cisgender counterparts.45-47 Barriers to getting services are pronounced for SGM youth experiencing homelessness.48 To address these inequities, we advise providers to tailor their outreach efforts to connect with and support SGM youth experiencing homelessness.
Immigration Status
No matter their legal status, immigrants often face severe barriers that prevent them from getting health insurance and care. Non-citizens without “qualified” immigration status are ineligible for Medicaid and are more likely to be uninsured than U.S. citizens. Although non-citizens (i.e., lawfully present immigrants and undocumented immigrants) and citizens are equally likely to be employed, immigrants are more likely to work in low-wage jobs without healthcare benefits.49 Complicating matters, some immigrants may be fleeing persecution in their home countries based on their sexualities and gender identities. The effects of such minority stress can cause SGM immigrants to avoid health care because they may fear being “outed” to members of their ethnic community.50 Providers can improve access for SGM immigrants by providing culturally competent care directly relevant to the immigrant communities they serve.51 Finally, providers can support SGM immigrants by referring to outside services that focus on their health-related needs (e.g., housing, food, employment).50
Children and Youth
Children and youth who are SGM suffer adverse health and psychosocial outcomes at greater rates when compared to their heterosexual and cisgender peers.1 These outcomes include health issues like feeling sad or hopeless, high-risk substance use, and suicide. In addition, population-based studies confirm that SGM youth are also more likely than their peers to be subjected to bullying, threats, and violence at school and miss school due to safety concerns.52 Unsurprisingly, the negative impacts of such experiences can be worse for SGM youth of color.
SGM children and youth may experience several complications in accessing quality care that SGM adults do not experience. These complications have to do with parents or guardians who may or may not be aware of or supportive of their sexual orientation or gender identity, since these persons are often responsible for brokering their care. Because such situations may be impossible to gauge before intake, health professionals need to build trust with the young patient when assessing their health, mental health, and treatment options.
Solomon and colleagues53 offer suggestions for culturally competent intake interviews for SGM youth built around questions, such as:
- Tell me about the kinds of people that you’re attracted to or interested in romantically?
- Do you identify as straight, gay, bi, or something else?
- What does being (insert identity) mean to you?
- What name do you go by?
- What are your pronouns?
- Who have you told that you are (insert identity)? How did that go?
If the family struggles to cope with a child’s sexual orientation, gender identity, and/or gender expression, referral to an SGM-friendly behavioral health therapist, an LGBTQ resource center, or PFLAG could be lifesaving. Research demonstrates that having family support is one of the most decisive protective factors in preventing depression, anxiety, and suicide among SGM youth.54-56 In situations where families are not accepting, support from a provider or another respected adult may function as a protective factor.
Finally, primary care providers may require additional training for situations in which SGM youth wish to begin gender-affirming care, a topic we discuss at greater length in Chapter 9. The American Academy of Pediatrics supports the need for gender-affirming care for transgender and gender-diverse youth, yet few providers are trained in the available protocols and therapies.57
Seniors
Access to quality care is a big concern for many aging adults in the U.S. Barriers to care include, but are not limited to, a lack of transportation or family support; the daunting complexity of the healthcare system; problems with health insurance; poverty; racial and ethnic marginalization; poor patient- provider communication; and a dearth of health professionals with adequate geriatric preparation.58 That said, SGM seniors harbor these same concerns while facing a range of other disparities, including a greater likelihood to experience disability, poor mental health, and elevated rates of smoking and alcohol use.59 In addition to these challenges, many SGM seniors had lived through periods when society and the healthcare system were less supportive of SGM people than they are now. As a result, they may have developed coping strategies that could lead them to withhold important information about their identity and personal lives; this may hinder the ability of providers to get the richest picture necessary to conduct appropriate screening, diagnosis, and treatment.60; 61