Access-Related Health Concerns and Subsequent Forgone Care Among LGBT Adults

Background and Purpose:  Sexual and gender minorities represent a group with elevated mental health, primary and sexual health concerns relative to their heterosexual and cisgender counterparts. These disparities render access to effective health and mental health services an imperative for lesbian, gay, bisexual, and transgender (LGBT) people. This group, however, remains an under-served, and often ill-served, population. The current study considered the interaction of simultaneously occurring supply-side (service) and demand-side (care-seeker) factors that shape the care-seeking process. Specifically, it examined health care access as described by a diverse sample of LGBT participants living in a major US city. Building upon existing literature, this study explored participants’ understanding of the causes and consequences of barriers to health care access. This study asked three main questions: 1) Which issues related to health care access do a diverse sample of LGBT adults identify as major health concerns within their community?; 2) To what do they attribute the root cause of these access-related problems?; and 3) How do these access issues subsequently contribute to health and mental health disparities among the LGBT community?

Methods: This interview-based study was conducted with a sample of 40 self-identified LGBT adults living in New York City. Participants were recruited using purposive and snowball sampling techniques, including outreach to LGBT-specific health and social service providers. Twenty-nine participants who discussed health care access as a major health concern were included in the current study. The sample was between 21 and 68 years of age (M=46); a majority identified as African American or Black (62%), cisgender women (45%), and bisexual (41%). Over half of the participants identified themselves as poor (51.7%), and close to 45% of participants within the subsample considered themselves as someone who was living with a disability. Framework analysis was used to identify issues in supply- and demand-side dimensions of service access. Strategies to enhance rigor were used, including memoing, peer checking, researcher reflexivity, and ethical considerations.

Results: Supply-side issues included lack of competent providers, insensitive or discriminatory providers, and service cost. Root causes of supply-side barriers were all attributed to social-structural factors that worked to exclude and erase LGBT people from the institutions that shape the health and mental health systems. Demand-side issues included hesitancy around open communication with providers, lack of financial resources, and motivation to participate in care. Demand-side barriers were attributed to both individual and social-structural factors. Supply- and demand-side barriers were related to forgone care, and led to other health and mental health concerns within the community.

Conclusions and Implications: Addressing supply- and demand-side issues at the individual and socio-structural levels will better serve LGBT communities. Policies set forth by the Patient Protection and Affordable Care Act (e.g., non-discrimination protections, expanded insurance coverage) remain important initiatives to promote equitable health care access and enhance the health and wellbeing of LGBT care-seekers. Tailored engagement strategies may also alleviate some of the barriers for LGBT people in accessing and fully participating in care.