Violence, Health Behaviors, Healthcare Access, Mental Health and Disability Among LGBTQ+ Adults: Application of a Structural Equation Model

Background and Purpose: Increasing diversity and rapidly evolving sociopolitical context are changing how sexuality and gender are expressed in contemporary America. LGBTQ people experience significant health disparities compared to heterosexual adults of similar age, and are more likely to report experiences of violence, adverse health behaviors, lack of access to care, poor mental health and physical limitations and disability. Yet, to date, much less is known about the mechanisms and associations between these risk factors and poor health. We investigate experiences of violence and the pathways accounting for adverse and health promoting behaviors, lack of access to care and mental and physical health.

Methods: We analyzed data from Wellness with Pride (N = 719) collected in 2020/21 from LGBTQ people aged 18 and older living in the U.S. Using Mplus 8, we performed Structural Equation Modeling via Maximum Likelihood Estimation with three latent variables and three observed variables. Measurement models were estimated using CFA for violence experience with two indicators, i.e., verbal and physical violence; for health-promoting behavior with three indicators of physical activity, fruit or vegetable consumption, and healthy sleep hours; and for health-risk behavior with three indicators of smoking, excessive drinking, and drug use. Structural paths were estimated with observed variables of poor mental health, health care access, and physical limitations and disability. The model was estimated holding demographic variables constant.

Results: The sample consists of 41% women, 41% men, and 18% gender diverse participants. Twenty-percent were transgender. Sixty-percent of the sample were lesbian or gay, 20% queer, 13% bisexual, and 7% sexually diverse. CFA displayed good fit to data (RMSEA = .038; CFI = .927; SRMR = .031), and statistically significant measurement paths. The structural model revealed that experiences of violence had direct effects on increased likelihoods of health-risk behaviors and decreased likelihoods of health-promoting behaviors. Experiences of violence were also associated with decreased likelihoods of access to health care. In addition to these direct effects, violence experiences indirectly affected low health-promoting behaviors and low access to care through its effect on poor mental health (b = 0.176, p<.001). Lower access to care was linked to elevated physical limitations and disability.

Conclusions and Implications: This study provides support for the HEPM as a framework for investigating diverse pathways culminating in adverse health outcomes and highlighting multiple mechanisms of risk. Greater attention to the sequelae of violence among LGBTQ people is warranted. Providers must remain aware of the historical and contemporary contexts in which LGBTQ adults live and the critical role of violence in health disparities. This information is needed to develop tailored interventions that address these mechanisms and result in the reduction of risk-behaviors, promote positive-health behaviors and ensure greater access to care. Testing of both upstream and downstream interventions is necessary to prevent and reduce the likelihood of violence as well as to mitigate its impact on the health and well-being of LGBTQ adults.