- What are the facilitators and barriers to health care for lesbian, gay and bisexual (LGB) people?
Key take-home messages
- The health of LGB people are affected by a range of social, structural and behavioural factors. As a result, LGB populations have unique health needs that may not be met by existing health care services (1;2).
- Barriers to LGB persons accessing health care services include the following:
- Some health care professionals lack knowledge of LGB persons’ health care needs or have negative attitudes towards LGB people (3-6).
- LGB persons may delay or avoid seeking services because of their experiences of past discrimination or perceived homophobia within the health care system (3;4).
- Some LGB persons are reluctant to disclose their sexual orientation, which may mean they do not receive appropriate care (5;6).
- Access may be affected by LGB persons’ ethnicity, education and income level, geographic isolation, immigration status, knowledge and cultural beliefs.
- To overcome these barriers, a number of large cities now have lesbian, gay, bisexual and transgender (LGBT) health care centres that provide comprehensive, culturally sensitive care (7-12). These centres focus on providing mental health, parenting, mentoring and legal services, as well as medical and prevention services.
The issue and why it’s important
The health and health care needs of LGB persons are affected by a number of social, behavioural, and structural factors including deep-rooted stigma and discrimination and health insurance policy. A limited body of literature documents a number of health issues that disproportionately affect sexual minorities including mental health issues, substance use, and tobacco use (2):
- Mental health disorders, particularly depression and anxiety are of significant concern among gay and bisexual populations (2).
- There is a higher prevalence of eating disorders among gay and bisexual men compared to heterosexual men.
- Compared to women of other sexual orientations, lesbians are more likely to be overweight or obese, which increases their risk for cardiovascular disease.
- LGB populations face increased risk of some cancers, which may go unrecognized. For example, health care providers may underestimate the risk of cervical cancer in lesbians — even though lesbians face multiple risk factors for cervical cancer such as early sexual debut with men (1). For men who have sex with men, anogenital cancers are a significant health concern (2). A study (13) of 319 men who have sex with men from Los Angeles found an overall HPV prevalence of 93%, as well as a 64% prevalence of high risk human papillomavirus strains. In another study, pooled anal cancer incidence was 45.9 per 100,000 HIV-positive men who have sex with men and 5.1 per 100,000 among HIV-negative men who have sex with men — compared to two per 100,000 in men overall (14).
The health care needs of LGB persons may not be adequately addressed either because their health care providers may be unaware of their sexual orientation, and they may face specific health issues. Moreover, some patients may have a perception of discrimination in the health system (1).
Analysis of Canadian Community Health Survey data (2003-2005) by Tjepkema (15) found that LGB persons were more likely to visit mental health service providers than heterosexuals – an indicator of the prevalence of mental health issues in LGB populations. Other studies indicate that:
- Lesbians have lower rates of using family doctors, and receiving pap smear and clinical breast examinations (5;15;16)
- Bisexual persons report higher levels of unmet healthcare needs than heterosexuals (15).
- LGB persons perceive that they have less equitable access to health care and social services, and report higher unmet health needs compared to heterosexual persons (6;17). One study (17) of 472 LGBT and 7,412 heterosexual individuals found that LGBT persons were more likely to report unmet mental health care needs.
Given the health disparities and unique challenges that LGB persons experience, it is important to understand the facilitators and barriers to accessing health care and to consider current approaches to meet their health care needs.
What we found
Barriers to LGB Health Care
Knowledge and Attitudes of Health Care Professionals
Knowledge and attitudes of health care professionals can be a barrier to health care for LGB populations. Some LGB persons have reported being refused treatment, or experiencing verbal abuse and disrespectful behaviour from healthcare providers (3;18).
In a Swedish study, health care professionals were inattentive to the realities of lesbian patients. In a survey of 76 general practitioners by Westerstahl et al (19): only 37% of doctors were aware of having lesbian patients in their years of practice, only 5% asked about sexual identity and only 11% were aware of any health concerns specific to lesbians.
Some health care providers reported not having enough training to care for LGB persons and lacking knowledge of the health issues LGB populations face; this lack of knowledge leads some health care professionals to feel uncomfortable providing services to LGB patients (3). A Canadian qualitative study of lesbian cancer patients by Sindling et al (18) confirmed these physician perceptions: while only a minority of women reported being denied standard medical care, a majority sensed physician discomfort and reported a lack of attention by service providers to women’s sexual identities when providing psychosocial support.
Heteronormative discourses can shape health care education programs and prevent providers from learning about LGB health care needs (3;20); however, there are effective strategies to influence provider knowledge and attitudes. An American study of 248 medical school students by Sanchez et al (4) found that students who had more clinical exposure to LGBT patients performed more comprehensive histories, had better attitudes toward LGBT persons, and had greater knowledge of LGBT health care concerns.
Discrimination and Reluctance to Disclose Gender Identity
LGB persons’ previous negative experiences with the health care system or perceptions of discrimination in the system may cause them to delay seeking health care. A study of 173 lesbians in three American cities found that the amount of discussion a woman had with her care provider and, to a lesser extent, the care she received and frequency of service use, was influenced by perceived homophobia and heterosexism of health care providers (21).
LGB persons may also be reluctant to disclose their sexual orientation out of fear that information will bias their care. In an American study of 132 LGBT persons by Jackson et al (6), the authors found that respondents who believed that LGBT residents of long-term care facilities were victims of discrimination were more likely to believe that they would hide their sexual orientation if admitted to a care facility.
The degree to which an individual feels comfortable disclosing his or her gender identity appears to be related to health care access and utilization (22). Being open about one’s sexual identity in general is related to increased disclosure to health care professionals, which leads to better care (5).
Some LGB individuals are willing to open up and seek care from their health care provider; however, their decision may be influenced by the attitudes of the individuals themselves and of their health care providers. For example, one US-based study found that gay men who were more likely to disclose their sexual orientation perceived their doctors as gay-friendly and were open to speaking to their health care providers about other health issues (23). A Canadian study by Geddes et al (24) found that lesbians felt it was important to disclose their sexual orientation to their family doctor. The study also found that, although some women feared lower quality of health care upon disclosure, most were not concerned about a decrease in quality of care (24). According to another Canadian study of 254 lesbians, higher levels of education predicted more disclosure to health care providers and better utilization of health services (5).
In the US, LGB persons experience barriers to accessing health insurance coverage (2;3) and may forgo care due to costs. Health insurers may hinder LGB peoples’ access to care. Some insurers do not cover domestic partners, denying health insurance coverage to unmarried partners of employed LGB people.
The barriers that LGB people face in accessing care may be compounded by other factors including racial status, education and income level, geographic isolation, immigration status, knowledge and cultural beliefs (3).
Facilitators to LGB Health Care
None of the papers reviewed focused solely on factors that facilitate access for LGB people. However, a small portion of the studies identified factors that could improve or facilitate LGB health care, including the:
- Creation of a safe, gay-positive space, free from violence and discrimination that LGB persons frequently face (25).
- Development of trust in relationships and respect of privacy during service delivery (25).
- Use of outreach services to LGB communities. In an American qualitative study by Dodge et al (26) of 75 men, participants recommended a number of outreach locations to reach populations of gay and bisexual men, such as bars, clubs, social spaces and the Internet.
- Provision of culturally competent care and referrals. A review article by Mayer et al (8) on integrated comprehensive care for men who have sex with men emphasized culturally competent care based in human rights principles, and stressed the importance of gathering the appropriate information to be able to provide care and make referrals and developing a strong rapport with patients in order to maintain routine care such as cancer screening and sexually transmitted infection testing (8).
- Creation of anti-discriminatory health policies at the governmental and institutional level to facilitate the development of equitable and accessible health services.
LGB Health Care Centres
To ensure access to services, it is important to create health care environments that provide medical treatment, counseling and referral services that support LGBT people in adopting healthy lifestyles. Three of 12 LGBT Health Centres in the US are described below (information on the remaining nine can be found at: http://www.cdc.gov/LGhealth/health-services.htm) along with a US-based access project. Information about one Ontario-based health care program is also described below.
Fenway Community Health Centre, Boston
Fenway Community Health Centre, founded by community activists in 1971, provides care to the Fenway neighbourhood of Boston (27). In the 1980s, it began providing medical services for gay men in response to the HIV/AIDS epidemic. Since then, the centre has increased its expertise in LGBT care, providing expanded services that include substance use, parenting services, domestic and homophobic violence services, as well as specialized programs for LGBT groups (27). It has established itself as a leader in the area of LGBT care, replicating its programs elsewhere in the US (25). In addition to developing unique programs for community health education and promotion, community-based research, and health policy advocacy, the centre has established standards for health service providers to ensure cultural competency in LGBT health issues and has developed LGBT materials for the community at large (27).
Howard Brown Health Centre, Chicago
The Howard Brown Health Centre, founded in 1974, is now one of the US’s largest LGBT organizations, offering discounted medical and psychiatric care and mental health counseling to Chicago’s uninsured and low income persons (28). The centre provides care in seven major programmatic areas: primary medical care, behavioural health, research, sexually transmitted infection prevention, youth services, elder services and community services (28). Throughout its history, the centre has partnered with numerous organizations to provide leading care to Chicago’s LGBT community (28). Its initiatives include the Lesbian Community Cancer Project, which enabled the organization to serve the lesbian, bisexual and transgender community through education, out-reach programs and direct-care services; and the National Gay and Lesbian Task force, which created a comprehensive lesbian and gay senior care program (28). In September 2013, the centre opened Aris Health, a new facility that provides comprehensive primary health care and medical and behavioural support to the LGBT community (9).
L.A. Gay & Lesbian Centre, Los Angeles
The L.A. Gay & Lesbian Centre provides a comprehensive array of services for the Los Angeles LGBT community (10). The centre offers free and low-cost medical and mental health services, addiction recovery services, LGBT youth mentoring services, HIV/AIDS medical care, and STI testing and prevention services. As part of its holistic approach to health, the centre also offers legal, social, cultural and health educational services with unique programs for families, youth and seniors. The centre aims to empower LGBT persons to: lead full and rewarding lives without limits based in gender identity; heal damage caused by discrimination; and advocate for full access and equality for everybody, regardless of sexual orientation (10).
GLBT Health Access Project
The Gay, Lesbian, Bisexual and Transgender Access Project is a US-based collaboration working to eliminate barriers to health for the LGBT community (7). The project works to create a supportive environment to develop wide-ranging, culturally appropriate health promotion policies and health care services for LGBT persons – primarily by disseminating community standards of practice for care providers and organizations and by collecting research data on LGBT health access concerns (7).
Sherbourne Health Centre, Toronto, Ontario
The Sherbourne Health Centre offers a wide range of primary health care services for Toronto-based LGBT persons with or without health care coverage (11). Services provided include treatment and monitoring of chronic illnesses, preventative health care, mental health counseling, LGBT youth mentoring, parenting services and health promotion. The centre aims to promote client health and wellness by addressing LGBT-specific health in an open, safe and welcoming environment (11). The Sherbourne Health Centre also initiated Rainbow Health Ontario in 2008, a program designed to improve the LGBT community’s access to services (12), which acts as the driving force behind improving services, increasing knowledge and encouraging networking and collaboration through education, research, outreach and public policy advocacy (12).
What we did
We searched Medline for articles using a combination of text terms [(LGBT) or (gay) or (lesbian) or (homosexual) or (men who have sex) or (MSM)] and [text terms (health care) or (facilitator*) or (barrier*) or (access*) or MeSH terms (delivery of health care, integrated) or (health services accessibility)]. The search was limited to articles published since 1993 in English.
Factors that may impact local applicability
All studies included in this summary were conducted in high income countries similar to Canada. Much of the literature on the facilitators and barriers of LGB health care was qualitative in nature, and came from secondary sources such as reports, review papers and guidelines for care for LGB populations. Much of the literature in this area was collected among lesbians. Studies on the facilitators and barriers to health among men who have sex with men and bisexual individuals were rarer. Most of the health care centres described in this review were designed and implemented in the US, which is an important consideration because health care insurance coverage and funding of health centres can vary between Canada and the US.
- Lee R. Health care problems of lesbian, gay, bisexual, and transgender patients. Western Journal of Medicine 2000;172(6):403-8.
- Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. Sexual and gender minority health: what we know and what needs to be done. American Journal of Public Health 2008;98(6):989-95.
- Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understand-ing. Washinton, DC: The National Academies Press; 2011.
- Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. Medical stu-dents’ ability to care for lesbian, gay, bisexual, and transgendered patients. Family Medicine 2006;38(1):21-7.
- Bergeron S, Senn CY. Health care utilization in a sample of Canadian lesbian women: Predictors of risk and resilience. Women & Health 2003;37(3):19-35.
- Jackson NC, Johnson MJ, Roberts R. The potential impact of discrimi-nation fears of older gays, lesbians, bisexuals and transgender individu-als living in small- to moderate-sized cities on long-term health care. Journal of Homosexuality 2008;54(3):325-39.
- Clark ME, Landers S, Linde R, Sper-ber J. The GLBT Health Access Project: a state-funded effort to improve access to care. American Journal of Public Health 2001;91(6):895-6.
- Mayer KH, Bekker LG, Stall R, Gru-lich AE, Colfax G, Lama JR. Compre-hensive clinical care for men who have sex with men: an integrated approach. [Review]. The Lancet 2012 28;380(9839):378-87.
- Howard Brown Health Centre Opens Aris. http://www.howardbrown.org/hb_news.asp?id=2712 Accessed on: October 21, 2013 2013;
- L.A. Gay & Lesbian Center: Mission & Values. http://laglc.convio.net/site/PageServer?pagename=YC_Who_We_Are Ac-cessed on: October 21, 2013 2013;
- Sherbourne Health Centre: How can we help? http://sherbourne.on.ca/programs/programs.html Accessed on: Octo-ber 21, 2013 2013;
- Rainbow Health Ontario: About Us. http://www.rainbowhealthontario.ca/about/whoWeAre.cfm Accessed on: October 21, 2013 2013;
- Cranston RD, Murphy R, Weiss RE, Da CM, Palefsky J, Shoptaw S et al. Anal human papillomavirus infec-tion in a street-based sample of drug using HIV-positive men. Inter-national Journal of STD & AIDS 2012;23(3):195-200.
- Johnson LG, Madeleine MM, New-comer LM, Schwartz SM, Daling JR. Anal cancer incidence and survival: the surveillance, epidemiology, and end results experience, 1973-2000. Cancer 2004 15;101(2):281-8.
- Tjepkema M. Health care use among gay, lesbian and bisexual Canadians. Health Reports 2008;(1):53-64.
- Diamant AL, Wold C, Spritzer K, Gelberg L. Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women. Archives of Family Medicine 2000;9(10):1043-51.
- Burgess D, Tran A, Lee R, van RM. Effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual and transgender persons. Journal of LGBT Health Research 2007;3(4):1-14.
- Sinding C, Barnoff L, Grassau P. Homophobia and heterosexism in cancer care: the experiences of lesbians. Canadian Journal of Nurs-ing Research 2004;36(4):170-88.
- Westerstahl A, Segesten K, Bjorkelund C. GPs and lesbian women in the consultation: issues of awareness and knowledge. Scandinavian Journal of Primary Health Care 2002;20(4):203-7.
- Rondahl G. Heteronormativity in health care education programs. Nurse Education Today 2011;31(4):345-9.
- Dehart DD. Breast health behavior among lesbians: the role of health beliefs, heterosexism, and homo-phobia. Women & Health 2008;48(4):409-27.
- Gay and Lesbian Medical Associa-tion and LGBT health experts. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexu-al, and Transgender (LGBT) Health. San Francisco, CA; 2001.
- Klitzman RL, Greenberg JD. Pat-terns of communication between gay and lesbian patients and their health care providers. Journal of Homosexuality 2002;42(4):65-75.
- Geddes VA. Lesbian expectations and experiences with family doc-tors. How much does the physi-cian’s sex matter to lesbians? Ca-nadian Family Physician 1994;(40):908-20.
- Brotman S, Ryan B, Jalbert Y, Rowe B. The impact of coming out on health and health care access: the experiences of gay, lesbian, bisexu-al and two-spirit people. Journal of Health & Social Policy 2002;15(1):1-29.
- Dodge B, Schnarrs PW, Goncalves G, Malebranche D, Martinez O, Reece M et al. The significance of privacy and trust in providing health-related services to behavior-ally bisexual men in the United States. AIDS Education & Preven-tion 2012;24(3):242-56.
- Mayer K, Appelbaum J, Rogers T, Lo W, Bradford J, Boswell S. The evolution of the Fenway Community Health model. American Journal of Public Health 2001;91(6):892-4.
- Howard Brown Health Center: Mis-sion and Overview. http://www.howardbrown.org/hb_aboutus.asp?id=153 Accessed: October 21, 2013 2013;
Rapid Response Service. Facilitators and barriers to health care for lesbian, gay and bisexual (LGB) people. Toronto, ON: Ontario HIV Treatment Network; March, 2014.
Sanjana Mitra and Jason Globerman