Health Care Issues Among Lesbian,Gay, Bisexual,Transgender and Intersex (LGBTI) Populations in the United States: Introduction

ABSTRACT

This supplemental issue of the Journal of Homosexuality presents research that explores a variety of health care issues encountered by lesbian, gay, bisexual, transgender and intersex (LGBTI) population groups in the United States over the 10-year period from 1993 to 2002.

Topics include access to health care, utilization of care, training of medical and mental health providers, and the appropriate preparation of clinical offices and waiting areas. Authors used a variety of community-based public health research methods, including participant and provider surveys and retrospective chart reviews of patients, to develop this body of research, providing a recent-historical perspective on the complex health care and health-related needs of sexual and gender minorities. Particularly for transgender and intersex populations, the state of research describing their health care needs is in its infancy, and much remains to be done to design effective medical and mental health programs and interventions.     

Health Care Needs and Care Utilization Among Lesbian,Gay, Bisexual,and Transgender Populations in New Jersey

The purpose of this study was to explore prevalent health issues, perceived barriers to seeking health care, and utilization of health care among lesbian, gay, bisexual, and transgender (LGBT) populations in New Jersey. A cross-sectional online survey was administered to 438 self-identified LGBT people. Results identified health needs, which included management of chronic diseases, preventive care for risky behaviors, mental health issues, and issues related to interpersonal violence. Barriers to seeking health care included scarceness of health professionals competent in LGBT health, inadequate health insurance coverage and lack of personal finances, and widely dispersed LGBT inclusive practices making transportation difficult. There is a need for better preparation of health care professionals who care for LGBT patients, to strengthen social services to improve access and for better integration of medical and social services.     

Intersex mental health and social support options in pediatric endocrinology training programs

The birth of a child with an intersex condition is often an emotionally stressful event for parents. Preparation and ongoing support systems could be beneficial to both parents and children and would alleviate some of the shame and isolation associated with intersex conditions. To assess the extent to which psychological support is available, a short e-mail survey on this topic was sent to the directors of 50 pediatric endocrinology fellowship training programs (PEFTPs), who are most likely to evaluate and treat intersex children and their parents. Of the 29 PEFTPs that responded, 69% offer psychological support and 58% have a mental health specialist on staff. However, only 19% of patients or families receive emotional support during diagnosis and only 15% receive support after diagnosis. We found two barriers that prevent patients and families from receiving psychological help from their intersex care team. First, there is a lack of training for mental health professionals regarding the needs of intersex patients and families. Second, some families refuse help even though it is offered. This study reveals that further research is needed to overcome these two barriers regarding mental health treatment of intersex patients and families.     

Intersex Mental Health and Social Support Options in Pediatric Endocrinology Training Programs

ABSTRACT

The birth of a child with an intersex condition is often an emotionally stressful event for parents. Preparation and ongoing support systems could be beneficial to both parents and children and would alleviate some of the shame and isolation associated with intersex conditions. To assess the extent to which psychological support is available, a short e-mail survey on this topic was sent to the directors of 50 pediatric endocrinology fellowship training programs (PEFTPs), who are most likely to evaluate and treat intersex children and their parents. Of the 29 PEFTPs that responded, 69% offer psychological support and 58% have a mental health specialist on staff. However, only 19% of patients or families receive emotional support during diagnosis and only 15% receive support after diagnosis. We found two barriers that prevent patients and families from receiving psychological help from their intersex care team. First, there is a lack of training for mental health professionals regarding the needs of intersex patients and families. Second, some families refuse help even though it is offered. This study reveals that further research is needed to overcome these two barriers regarding mental health treatment of intersex patients and families.     

Intimate Partner Violence Among Sexual Minorities in Japan: Exploring Perceptions and Experiences

Using qualitative interviews (n = 39) and participant observation (n = 54), this study documents perceptions and experiences of violence between lesbian, gay, bisexual, transgender, and intersex intimate partners in Japan, thereby providing exploratory, formative data on a previously unexamined issue. Results indicate that intimate partner violence (IPV) is experienced physically, sexually, and psychologically in all sexual minority groups. Participants perceived the violence to be: a) very similar to heterosexual IPV against women; b) more likely perpetrated and experienced by lesbians, bisexual women, and transgender persons compared to gay and bisexual men and intersex persons; c) the cause of several negative physical and mental health outcomes; and d) largely unrecognized in both sexual minority communities and broader Japanese society.     

Primary Care Providers’ Attitudes,Practices, and Knowledge in Treating LGBTQ Communities

ABSTRACT

Cultural competency in lesbian, gay, bisexual, transgender, and queer (LGBTQ) health care has been found to be lacking within various medical specialties, but no studies have compared competency among primary care providers. The authors compared 127 primary care providers’ cultural competency regarding LGBTQ health using a survey that assessed providers’ attitudes, practices, and knowledge. Overall, 78.0% of respondents agreed that they were comfortable treating LGBTQ patients. Yet many providers did not feel well informed on specific LGBTQ health needs (70.1%), on clinical management of LGBTQ care (74.8%), nor on referring patients with LGBTQ issues (78.7%). Overall accuracy on LGBTQ knowledge questions was 51.0%. This study revealed a lack of cultural competency and much need for improvement as primary care providers endorsed negative attitudes, biases, inconsistencies in clinical practice, and deficiencies in medical knowledge in specialty-specific ways. There is a need for greater LGBTQ-specific education to increase providers’ comfortability and competency in the needs, management, and referrals within LGBTQ health care.     

Slivers of the journey: the use of photovoice and storytelling to examine female to male transsexuals' experience of health care access

The purpose of this research project was to examine female to male transsexuals' (FTMs) experiences of accessing health care. This was accomplished by documenting and recording the experiences of five FTMs through the use of photography and interviews. It was hoped that such an inquiry would provide a starting point for future research about the health care needs of the transgender community, and document some of the health care needs of the FTM community that would lead to recommendations for policy changes and educating providers.     

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

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.     

Is the Lack of Specific Lesbian,Gay, Bisexual,Transgender and Queer/Questioning (LGBTQ) Health Care Education in Medical School a Cause for Concern? Evidence From a Survey of Knowledge and Practice Among UK Medical Students

Lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people frequently report negative health care encounters. Medical professionals may inadequately manage LGBTQ persons’ health if they have not received training in this area. An anonymous survey measuring efficacy in health situations among LGBTQ persons was answered by 166 medical students across all years of a UK university. Results show that 84.9% of participants reported a lack of LGBTQ health care education, with deficits in confidence clarifying unfamiliar sexual and gender terms, deciding the ward in which to nurse transgender patients, finding support resources, and discussing domestic abuse with LGBTQ patients. Most participants reported that they would not clarify gender pronouns or ask about gender or sexual identity in mental health or reproductive health settings. Participants reported infrequently observing doctors making similar inquiries. Participants held positive attitudes toward LGBTQ patients, with attitude scores positively correlating with LGBTQ terminology knowledge scores (r_s = 0.5052, p < .01). Addressing gender identity and sexuality issues within medical curricula may remove barriers to accessing health care and improve encounters for LGBTQ patients.     

A Comparison of Mental Health,Substance Use,and Sexual Risk Behaviors Between Rural and Non-Rural Transgender Persons

The aim of this study was to compare the mental health, substance use, and sexual risk behaviors of rural and non-rural transgender persons. Online banner advertisements were used to recruit 1,229 self-identified rural and non-rural transgender adults (18+ years) residing in the United States. Primary findings include significant differences in mental health between rural and non-rural transmen; relatively low levels of binge drinking across groups, although high levels of marijuana use; and high levels of unprotected sex among transwomen. The results confirm that mental and physical health services for transgender persons residing in rural areas are urgently needed.     

Resilience to Discrimination and Rejection Among Young Sexual Minority Males and Transgender Females: A Qualitative Study on Coping With Minority Stress

Sexual minority and transgender status is associated with mental health disparities, which have been empirically and theoretically linked to stressors related to social stigma. Despite exposure to these unique stressors, many sexual minority and transgender individuals will not experience mental health disorders in their lifetime. Little is known about the specific processes that sexual minority and transgender youth use to maintain their wellbeing in the presence of discrimination and rejection. Semistructured interviews were conducted with 10 sexual minority males and transgender females aged 18–22 years, who currently met criteria for an operationalized definition of resilience to depression and anxiety. Data were analyzed qualitatively, yielding information related to a wide variety of problem-solving, support-seeking, and accommodative coping strategies employed by youth in the face of social stigma. Results are discussed in light of their clinical implications.     

High Rates of Access to Health Care,Disclosure of Sexuality and Gender Identity to Providers Among House and Ball Community Members in New York City

The House and Ball community is an important cultural manifestation of resiliency for Black and Latino gay and bisexual men and transgender women. Participants at the August 2013 House of Latex Ball in New York City were surveyed about insurance coverage, health care access, experiences in health care, and housing instability. The sample (n = 367) was 58% Black/African American and 20% Hispanic/Latino, with a mean age of 31. Fifty-five percent were gay and bisexual men. Although only 6% identified as transgender, nearly one half were gender nonconforming. Strong majorities had health insurance, were in regular medical care, and were “out” to their providers. Some were unstably housed and had recently exchanged sex for shelter or money. High rates of health care access and disclosure indicate resiliency and agency. Unstable housing and income insecurity may be structural drivers of vulnerability for this population to HIV infection and other health risks.     

Mental Health of Transgender People in Hong Kong: A Community-Driven,Large-Scale Quantitative Study Documenting Demographics and Correlates of Quality of Life and Suicidality

A community-driven survey of 106 transgender people (the first such survey in Hong Kong) showed that: (1) more than half the sample (50.9%) had a university degree or higher qualification; (2) despite this, 43.4% had a monthly income below HK$6,000 (about USD$775); (3) 66% reported “fair” or “poor” quality of life; (4) 67% of the sample (87.1% of respondents aged 15–24 years) had contemplated suicide; and (5) 20.8% of the sample (35.5% of respondents aged 15–24 years) had attempted suicide. It was found that (1) those who were single, had a lower monthly income, and identified as transgender women reported lower quality of life; and (2) those who were younger and on a lower income expressed higher suicidality. The findings suggest that service providers and policy makers urgently need to address the mental health needs of transgender people, particular younger transgender people.     

Trend Analysis of Medical Publications About LGBT Persons: 1950–2007

Although there are currently at least 6 million lesbian, gay, bisexual, and transgender (LGBT) persons in the United States, there are no prior studies analyzing how this group is represented in the medical literature. An examination of published LGBT topics over a 57-year period was performed using OvidSP. A total of 21,728 publications was analyzed for topic using information from the title, keywords, subject headings, and abstracts. Several trends became apparent. The largest proportion of LGBT publications (31.78%) was devoted to HIV/AIDS and other sexually transmitted infections (STIs), yet there was an overall lack of emphasis on general health topics or common causes of mortality. Further analysis showed that if publications on HIV/AIDS or STIs addressed sexual orientation, they were more likely to be about LGBT persons than heterosexuals. Overall, the volume and range of medical publications on LGBT persons may not be reflective of the health care needs of this population.     

Trend analysis of medical publications about LGBT persons: 1950-2007

Although there are currently at least 6 million lesbian, gay, bisexual, and transgender (LGBT) persons in the United States, there are no prior studies analyzing how this group is represented in the medical literature. An examination of published LGBT topics over a 57-year period was performed using OvidSP. A total of 21,728 publications was analyzed for topic using information from the title, keywords, subject headings, and abstracts. Several trends became apparent. The largest proportion of LGBT publications (31.78%) was devoted to HIV/AIDS and other sexually transmitted infections (STIs), yet there was an overall lack of emphasis on general health topics or common causes of mortality. Further analysis showed that if publications on HIV/AIDS or STIs addressed sexual orientation, they were more likely to be about LGBT persons than heterosexuals. Overall, the volume and range of medical publications on LGBT persons may not be reflective of the health care needs of this population.     

城乡差异、就医惯性与老年人卫生服务利用

现有对城乡老年人卫生服务利用不公平的研究多忽略了长期的城乡差异所导致的隐性的农村老年人就医惯性的存在。本研究在控制了收入、医疗保障和就医可及性等因素的条件下,发现就医惯性的存在;并运用集中指数分解法发现,卫生服务的利用存在不公平,偏向于富人,而就医惯性在两种卫生服务利用中的贡献度分别为12%和5%。这种城乡固定差异造成了农村老年人在身体健康、心理健康和自我照料能力上都显著地低于城市老年人。     

Transgender youth: invisible and vulnerable

This study used three focus groups to explore factors that affect the experiences of youth (ages 15 to 21) who identify as transgender. The focus groups were designed to probe transgender youths' experiences of vulnerability in the areas of health and mental health. This involved their exposure to risks, discrimination, marginalization, and their access to supportive resources. Three themes emerged from an analysis of the groups' conversations. The themes centered on gender identity and gender presentation, sexuality and sexual orientation, and vulnerability and health issues. Most youth reported feeling they were transgender at puberty, and they experienced negative reactions to their gender atypical behaviors, as well as confusion between their gender identity and sexual orientation. Youth noted four problems related to their vulnerability in health-related areas: the lack of safe environments, poor access to physical health services, inadequate resources to address their mental health concerns, and a lack of continuity of caregiving by their families and communities.     

Hungarian Medical Students’ Knowledge About and Attitude Toward Homosexual,Bisexual, and Transsexual Individuals

ABSTRACT

Discrimination that LGBTQ individuals experience in health care settings might affect their health and intention of using health care services. However, health needs of LGBTQ patients are still inappropriately addressed in the medical curriculum. First-, third-, and fourth-year medical students (N = 569) from the four Hungarian medical universities participated in a study in 2017 to assess knowledge about homosexuality, homonegativity, and their attitude as health care professionals toward sexual minorities. We found that higher levels of knowledge about homosexuality were associated with lower levels of homonegativity, upper-grade level in university, not being religious, and having close LGBTQ acquaintances. Our results suggest that it may be necessary to introduce LGBTQ themes in the medical curricula (not only in Hungary, but also in other countries) in order to improve the knowledge and attitude of medical students and thereby improve the health care of LGBTQ individuals.     

Lesbian, gay, bisexual, and transgender (LGBT) physicians' experiences in the workplace

Little is known about the experiences of lesbian, gay, bisexual, and transgender (LGBT) physicians in the workplace. There is little formal education in medical school about LGBT issues, and some heterosexual physicians have negative attitudes about caring for LGBT patients or working with LGBT coworkers, setting the stage for an exclusive and unwelcoming workplace. The current study used an online survey to assess a convenience sample of 427 LGBT physicians from a database of a national LGBT healthcare organization, as well as a snowball sample generated from the members of the database. Although rates of discriminatory behaviors had decreased since earlier reports, 10% reported that they were denied referrals from heterosexual colleagues, 15% had been harassed by a colleague, 22% had been socially ostracized, 65% had heard derogatory comments about LGBT individuals, 34% had witnessed discriminatory care of an LGBT patient, 36% had witnessed disrespect toward an LGBT patient's partner, and 27% had witnessed discriminatory treatment of an LGBT coworker. Few had received any formal education on LGBT issues in medical school or residency. It appears that medical schools and health care workplaces continue to ignore LGBT issues and operate in discriminatory fashion far too often.     

Persecution Experiences and Mental Health of LGBT Asylum Seekers

Asylum seekers are a unique population, particularly those who have endured persecution for their sexual orientation or gender identity. Little data exist about the specific experiences and needs of asylum seekers persecuted due to lesbian, gay, bisexual, or transgender (LGBT) identity. Quantitative data were gathered regarding demographics, persecution histories, and mental health of 61 clients from a torture survivors program in New York City who reported persecution due to LGBT identity. Thirty-five clients persecuted due to their LGBT identity were matched by country of origin and sex with clients persecuted for other reasons to explore how persecution and symptoms may differ for LGBT clients. LGBT asylum seekers have a higher incidence of sexual violence, persecution occurring during childhood, persecution by family members, and suicidal ideation. Understanding the type of persecution experiences and how these influence mental health outcomes is an essential step toward designing and delivering effective treatments.