Health Care Disparities Among Autistic LGBTQ+ People

Abstract

Background:

Lesbian, gay, bisexual, transgender, or queer (LGBTQ+) people and disabled people experience disparities in access to health care compared with others. However, we have yet to understand how health care disparities may be further exacerbated at the intersection of disability and LGBTQ+ identity, particularly among autistic people.

Objectives:

The primary goals of this study were to (1) examine differences in unmet health care needs and health status between LGBTQ+ autistic people and straight/cisgender autistic people and (2) explore how state policies and demographics predict the unmet health care needs of the autistic LGBTQ+ people.

Methods:

We conducted a cross-sectional analysis using data from the 2019 National Survey on Health and Disability that included a subsample of autistic participants, with 62 LGBTQ+ adults and 58 straight/cisgender adults. To address our first study goal, we used an independent samples t-test, and to address our second study goal, we used Poisson regression.

Results:

The LGBTQ+ group reported significantly more days of poor physical and mental health, more co-occurring diagnoses, and more unmet health care needs than the straight/cisgender group. For LGBTQ+ people, protective state health care laws and a lower income resulted in significantly more health care needs being met.

Conclusions:

Findings from this study suggest that the intersection of an LGBTQ+ identity and autism is associated with greater disparities in physical and mental health as well as unmet health care needs; however, state policies prohibiting discrimination of LGBTQ+ people may act as a protective factor and result in fewer unmet health care needs. Future research should examine additional structural factors that may mitigate health inequities for autistic LGBTQ+ people.

Community brief

Why is this an important issue?

More people in the autistic community identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ+) as compared with the general population. Previous research described poorer health outcomes and issues in accessing health care for LGBTQ+ people. We need to understand how identifying as both autistic and LGBTQ+ is related to health outcomes and getting health care needs met. This is important information to improve future health care access and reduce health care issues.

What was the purpose of this study?

We wanted to see whether there were differences between autistic/LGBTQ+ people and autistic/straight/cisgender people in accessing health care and health status. We also wanted to understand what factors contributed to unmet health care needs for autistic/LGBTQ+ people.

What did the researchers do?

Our team used data from the second wave of the National Survey on Health and Disability (NSHD) fielded from October 2019 through January 2020. The NSHD sample included 2175 disabled participants, and 120 participants of the sample self-identified as autistic. We compared responses of autistic/LGBTQ+ people with autistic/straight/cisgender respondents. We compared these two groups on responses related to the number of good mental and physical health days, number of unmet health care needs, and number of additional diagnoses. We also looked at whether a person's income, location, race, or ethnicity, as well as whether state laws that supported LGBTQ+ health care related to the increased unmet health care needs of the LGBTQ+ group.

What were the results of the study?

The results suggested that the autistic/LGBTQ+ group reported fewer good health days, more unmet health care needs, and more diagnoses. The authors also found that state-wide health care laws that protected LGBTQ+ people related to more health care needs being met. LGBTQ+ people with a lower income also had fewer unmet health care needs.

What do these findings add to what was already known?

These findings are like other studies suggesting that identifying as autistic and LGBTQ+ results in more unmet health care needs and poorer health status. Our study adds to what is already known by exploring how other factors relate to the increased unmet health care needs among autistic/LGBTQ+ people.

What are potential weaknesses in the study?

The NSHD subsample was small that may affect the study findings. Our sample also lacked diversity and primarily included White non-Hispanic/non-Latine participants, and those living in urban areas. The lack of diversity limits the generalizability of our findings. There are also many other factors (e.g., culture and provider knowledge) that may relate to unmet health care needs in autistic/LGBTQ+ people. Future research should investigate additional factors related to unmet health care needs.

How will these findings help autistic adults now or in the future?

The findings are important because few research studies have focused on health care access among autistic/LGBTQ+ people in the United States. This study indicates the health care system is not supporting positive health outcomes and health care needs of autistic/LGBTQ+ adults. We need to continue to develop ways to support training of providers to reduce unmet health care needs and support better health outcomes.

Introduction

Longstanding disparities exist in health care access and utilization for lesbian, gay, bisexual, transgender, or queer (LGBTQ+) populations.¹ That is, LGBTQ+ people typically have lower health care utilization and more unmet needs and are more likely to experience mental health issues and substance abuse compared with straight/cisgender people.^2–6 LGBTQ+ people often experience health care-related barriers due to interpersonal discrimination and stigma from providers, which may ultimately result in delaying or foregoing treatment.⁷

Furthermore, discrimination and stigma at the structural level (e.g., state policies and institutional practices) can act as a protective (i.e., low structural stigma) or risk factor (high structural stigma) for health outcomes.⁸ Similar disparities exist for people with disabilities; however, less is known about the health care experiences of people with these dual identities.⁹ A recent large-scale study (n = 27,715) reported that refusal of transspecific and general health care was magnified if the person also had a disability,¹⁰ and other studies have suggested that disabled transgender people have more unmet health care needs.^11,12

Thus, given that both LGBTQ+ and disability populations experience discrimination, disability status may exacerbate health disparities already recognized in LGBTQ+ research. More research is needed on the intersectionality of disability, minoritized gender identities and sexual orientations to understand health care utilization, and to improve future health care policies that may act as structural protective factors.

It is increasingly recognized that disparities exist for groups of autistic people; however, many gaps remain in the literature. To date, research has primarily identified disparities for marginalized racial and ethnic groups, women, people in rural areas, and people with a lower socioeconomic status (for review see Bishop-Fitzpatrick and Kind, 2017).¹³ Findings reveal these historically marginalized and excluded groups within the autistic community typically receive delayed diagnoses,^14,15 have less access to health care,^16–18 receive fewer specialty services,^19–21 or are more likely to have concerns dismissed by health care providers.²² Yet, limited data exist on the health disparities and experiences of gender nonconforming or sexual minority autistic people.²³

More autistic people identify as LGBTQ+ than the general population^24–26; yet, this group as a whole remains understudied. To date, much of the research has focused on the increased prevalence of gender diversity in autism and autistic transgender people.²⁷ These studies suggest that autistic transgender people have more mental health issues, as well as experience barriers to seeking treatment due to differences in executive function and social skills as compared with allistic/transgender people.^28–30 What is especially concerning is that autistic transgender people are at an increased risk for anxiety, depression, and suicidality.³¹

Although there is clearly a need for research on autistic transgender people to support better mental health services, this is only one subgroup of the LGBTQ+. More research is needed to gain a broad understanding of the health care experiences of diverse sexual and gender identities in autism to better compare and understand the specificity of these health care experiences to the more well-established LGBTQ+ literature describing health care disparities.

A few recent studies have used qualitative methods to examine the lived experiences of autistic/LGBTQ+ people, and interviewees often reported they experienced multiple stressors, a lack of services, inappropriate care, refusal by providers, difficulties with dual identities, isolation, and difficulty communicating sexual needs.^32–34 These lived experiences depict significant issues in the interactions between health care providers and autistic minoritized sexual and gender identity groups. There is a critical need for further study as autistic adolescents and adults are at a higher risk for mental health issues, such as depression, anxiety, and suicidality.^34–36 Because identifying as LGBTQ+ or as being autistic is associated with increased risks for mental health issues, the additive effect of these two identities may exacerbate these risks.

Less is known about how the health care experiences of autistic/LGBTQ+ people compare with autistic/straight/cisgender people. A previous study using the 2018 National Survey on Health and Disability (NSHD) (n = 1246) analyzed a subgroup of respondents (n = 54) who self-identified as autistic and LGBTQ+.³² Results indicated that autistic/LGBTQ+ people had more unmet health care needs, more mental health and psychiatric conditions, and twice as many poor physical health days when compared with autistic/straight/cisgender people.

Although this study was one of the first to examine the health care experiences of this population in the United States, the sample size was small, and we have yet to begin broadly investigating how factors at the structural level protect or add risk for those with dual identities. Therefore, the purpose of this study is to conduct analyses with the larger second wave of the NSHD conducted from October 2019 to January 2020.³⁷ Our research questions included (1) to what extent do unmet health care needs and health status differ between autistic/LGBTQ+ and autistic/straight/cisgender people and (2) what state policies and demographic variables predict the unmet health care needs of the LGBTQ+ group?

Methods

Survey

We conducted a cross-sectional analysis with data from the 2019 NSHD conducted between October 1, 2019, and January 31, 2020, in the United States. The purpose of the NSHD was to understand the health care access and experiences of people with disabilities after coverage expansions under the Affordable Care Act and other health care reforms were implemented. When developing the survey, the NSHD team conducted cognitive interviewing (including autistic people) to ensure questions were understandable and clear.

The feedback from testing and cognitive interviewing was integrated into the survey. The survey was primarily administered online through Qualtrics, but respondents were also given the option to complete the survey over telephone by calling a dedicated and accessible toll-free number.

Participants were recruited through three different methods across more than 80 disability organizations, including (1) announcements at national conferences (e.g., American Public Health Association Disability Section, AcademyHealth Disability Research Interest Group, Association of Programs for Rural Independent Living, National Council on Independent Living); (2) outreach through national disability organizations (e.g., Autistic Self-Advocacy Network, Autistic Women and Non-Binary Network, Center for Disability Rights); and (3) Amazon's Mechanical Turk (MTurk).³⁸

Respondents to the survey were (1) between 18 and 64 years of age, (2) resided in the United States, and (3) responded “yes” to the following question, “Do you have a physical condition, mental illness, impairment, disability or chronic health condition that can affect your daily activities and/or that requires you to use special equipment or devices, such as a wheelchair, walker, telecommunication device for the deaf or communication device?” Participants were provided the choice to enter their name in a drawing for 1 of 15, $100 prepaid gift cards. Participants who did not complete the survey could still enter the drawing, and survey responses were not connected to the participants' name or drawing entry.

We examined responses from the survey that addressed health status and unmet health care needs. All survey study protocols and procedures were approved by the University of Kansas Institutional Review Board (IRB, Study no. 00004253), and all participants provided informed consent to participate before beginning the online survey.

Sample

The NSHD yielded a total sample size of 2175 disabled adults, aged 18–64 years with a wide variety of disabilities and chronic health conditions.³⁷ For the purposes of this study, we included a subset of participants who self-reported autism as their primary diagnosis on the NSHD, which resulted in a subsample of 120 participants. Of the 120 participants, 62 identified as LGBTQ+ and 58 identified as straight/cisgender (see Table 1 for participant demographics). Gender identity and sexual orientation were determined through the demographics section of the survey.

Table 1.

Participant Demographics

Variable	N	ASD and LGBTQ+ (n = 62)	ASD (n = 58)	p a
		M (SD)	M (SD)
Age (years)	120	32.08 (8.58)	32.19 (10.80)	0.95

		% (n)	% (n)
Gender	120
Male		14.5 (9)	67.2 (39)	<0.01
Female		43.5 (27)	32.8(19)	0.22
Other		41.9 (26)	0 (0)	<0.01
Black or Latineb	115	6.6 (4)	29.1 (7)	0.27
Ruralc	120	14.5 (9)	22.4 (13)	0.26
Uninsuredd	118	6.6 (4)	5.3 (3)	0.77
Insured by Medicaid	116	42.6 (26)	56.4 (31)	0.14
Employed	120	59.7 (37)	50.0 (29)	0.29
Household income <100% FPL	120	33.9 (21)	48.3 (28)	0.11

^a Calculated with either a t-test or chi-square.

^b Five individuals selected “prefer not to answer” and were excluded from analyses.

^c Rural is defined as a county of residence with a population density <50,000 and (micropolitan and noncore categories) and metropolitan is defined as a county with a population density >50,000 using county-level Rural Urban Commuting Area codes.

^d Two individuals selected “not sure” in response to insurance type(s) and were excluded from analyses.

ASD, autism spectrum disorder; FPL, federal poverty level.

Participants were asked, “What is your sexual orientation?” and selected from the following options: (1) gay, lesbian, or homosexual; (2) straight or heterosexual; (3) bisexual, something else, asexual; and (4) prefer not to answer. Participants were also asked, “What is your gender?” and selected from the following options: (1) female, (2) male, or (3) other.

Those who responded as “other” were asked a subsequent open-ended question to write-in their specific gender identity (e.g., transgender, nonbinary, two-spirit, gender nonconforming, genderqueer, agender, and intersex). People reporting a sexual minority identity (i.e., gay, lesbian, homosexual, bisexual, something else, and asexual) and/or a gender minority identity (i.e., transgender, nonbinary, two-spirit, gender nonconforming, genderqueer, agender, and intersex) were included in the LGBTQ+ group.

Analysis

We first used descriptive statistics and chi-square or t-tests to determine any differences between the LGBTQ+ and straight/cisgender groups based on demographics. The two groups differed on gender, but not on other demographics (Table 1). Thus, to address our first research question, we used an independent samples t-test to examine group differences in unmet health care needs (i.e., physician, prescription drugs, mental health, specialty care, and preventative care), physical health status, mental health status, and the total number of co-occurring disabilities. For unmet health care needs, we transformed each of the five types of providers (i.e., physician, prescription drugs, mental health, specialty providers, and preventative providers) into a “total unmet health needs” summary variable.

Participants responded to the unmet needs questions as (1) yes, (2) no, (3) I don't know, and (4) I haven't needed/do not need this service. We added together the “yes” responses across the five provider questions, and all other responses were calculated as a 0 (i.e., “no,” “I don't know,” “I haven't needed/do not need this service.”). Thus, participant scores could range from 0 to 5 on total unmet needs (see Table 2 for survey questions).

Table 2.

Survey Questions Across Groups

Category	Survey questiona	Score range	ASD and LGBTQ+			ASD			p
			N	M (SD)	% (n)	N	M (SD)	% (n)
Health status	Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?	0–30	62	10.21 (9.40)		58	6.76 (9.50)		0.048
	Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?	0–30	62	16.68 (9.23)		58	10.21 (9.29)		<0.001
Health conditions/disability typeb	Open-ended question: “What is your disability and/or health condition(s)?”c
	Mental illness/psychiatric disability	0–1	62	—	80.65 (50)	58	—	44.83 (26)	<0.001
	Physical disability	0–1	62	—	25.81 (16)	58	—	13.79 (8)	0.100
	Chronic illness/disease	0–1	62	—	48.39 (30)	58	—	34.48 (20)	0.123
	IDD, autism, and cognitive	0–1	62	—	100 (62)	58	—	100 (58)	—
	Sensory	0–1	62	—	4.84 (3)	58	—	8.62 (5)	0.407
	Neurological	0–1	62	—	40.32 (25)	58	—	39.66 (23)	0.941
	Total no. of health conditions	1–6	62	3.00 (0.92)		58	2.41 (1.01)		0.001
Unmet health care needs	In the past 12 months, have you been able to…
	See the doctors you need to with your health insurance plan(s)?	0–1	56	—	26.79 (15)	51	—	11.76 (6)	0.051
	Get all the prescription medications you need with your health insurance plan(s)?	0–1	56	—	26.79 (15)	51	—	9.80 (5)	0.024
	See the specialists you need to with your health insurance plan(s)?c	0–1	51	—	21.57 (11)	50	—	20.00 (10)	0.846
	Get all the preventive health services and test you need?d	0–1	56	—	12.50 (7)	50	—	12.00 (6)	0.938
	Get all the mental health services and/or counseling services that you need?	0–1	56	—	41.07 (23)	51	—	15.69 (8)	0.004
	Total no. of unmet health needs	0–5	51	1.31 (1.62)	—	47	0.68 (1.14)	—	0.029

^a The text in this table provides the exact wording of all questions on the survey and for unmet needs bullet points to indicate each type of service/provider respondents were asked about.

^b Percentage total does not equal 100% as some respondents provided more than one condition/disability in response to the open-ended term.

^c Responses to this open-ended question were categorized by two of the authors into the six categories listed. Here are a few examples in each category: mental illness/psychiatric includes (e.g., bi-polar disorder, schizophrenia, depression, anxiety, mood disorders, post-traumatic stress disorder); physical disability (e.g., paraplegia, quadriplegia, limb loss/difference, spinal cord injury); chronic illness/disease (e.g., cancer, heart disease, asthma, kidney disease, chronic obstructive pulmonary disease, chronic fatigue syndrome; IDD, autism and cognitive (i.e., down syndrome, fragile-X, autism spectrum disorder); sensory (e.g., blindness, low vision, deafness, deafblindness, hard of hearing); and neurological (e.g., multiple sclerosis, traumatic brain injury, learning disabilities, epilepsy).

^d Specialist defined on survey as: A specialist is a doctor who focuses on a specific disease, such as heart disease or cancer, or a particular technique, such as surgery or gynecology.

^e Preventative health services defined on survey as: Procedures and tests that can detect certain conditions or disease and should be conducted regularly. Examples of preventive services include mammogram, bone density, colorectal screening, pap smear, prostate-specific antigen blood tests, etc.

IDD, intellectual and developmental disability.

For our second research question, we only included autistic people who identified as LGBTQ+. We used Poisson regression, since our dependent variable was count data, with total unmet needs as our dependent variable, and state legislation on health insurance for LGBTQ+ populations and demographic factors associated with disparities in health care (i.e., race, ethnicity, rural, and income below poverty level) as predictors.

Owing to missing data in the dependent variable, our total sample for this analysis is 51, and because of the small sample size, we created an aggregate variable based on two specific state health care laws, including (1) state health care law prohibits health insurance discrimination based on sexual orientation and (2) state health care law prohibits health insurance discrimination based on gender identity/expressions. This means that scores ranged from 0 (neither of these two health care laws were in place) to 2 (both of these health care laws were in place, see Fig. 1).³⁹

FIG. 1.

Visual representation of the equity-oriented state health care laws included in our analyses. The states represented are only from the autistic/LGBTQ+ group. State health care law data were obtained from, and this figure was adapted from, the Movement Advancement Project, which was accessed in January 2022.³¹

For race and ethnicity, we specifically examined people who reported their race as Black or their ethnicity as Latine, since these racial and ethnic groups often have more unmet service needs, receive fewer services, and receive later autism diagnoses as compared with White people.¹³ We categorized race as a binary Black/Latine or non-Black/Latine as our sample lacked additional racial and ethnic diversity. Unfortunately, upon examination of descriptive analyses, we removed this variable because only four people were Black or Latine in the LGBTQ+ group.

Next, we used the Rural-Urban Commuting Area codes to determine whether a participant lived in a metropolitan or rural area (i.e., micropolitan, small town core, and rural areas); however, when examining descriptive analyses, we also removed this variable because only 6 individuals resided in a rural area with the reduced 51-person sample.⁴⁰ Last, two income groups were created based on federal poverty level (FPL) in 2019,⁴¹ with one group including people <100% FPL, or below the FPL, and the other group including people ≥100% FPL, or above the FPL. All analyses were conducted using SPSS 28,⁴² and all missing data for analyses and variable transformations were accounted for with listwise deletion.

Results

Results addressing our first research question suggested significant differences between the LGBTQ+ and straight/cisgender group on variables of interest (Table 2). Specifically, analyses revealed that the LGBTQ+ group reported significantly more days of poorer physical (t(118) = −2.00, p = 0.048) and mental health (t(118) = −3.83, p < 0.001), as well as more unmet health care needs (t(96) = 6.24, p = 0.029) and a higher number of co-occurring diagnoses (t(118) = 0.16, p = 0.002).

When further examining the individual categories associated with the aggregated unmet service needs, results suggested unmet doctor (χ² = 3.82; p = 0.051), prescription (χ² = 5.07; p = 0.0024), and mental health (χ² = 8.36; p = 0.004) services were driving group differences on total unmet needs. In addition, when examining individual co-occurring diagnostic categories, it appears that mental health conditions (χ² = 18.02; p < 0.001) were driving the group differences in the total number of co-occurring health conditions (Table 2).

For our second research question, we used Poisson regression to predict total unmet health care needs in the autistic/LGBTQ+ group. Overall, results suggested a strong model fit χ² (2) = 16.47; p < 0.001 (Table 3). Specifically, the number of health care laws prohibiting discrimination based on gender identity/expression and sexual orientation significantly predicted total unmet health care needs, and those with more health care laws prohibiting discrimination were 0.60 times less likely to have unmet health care needs (Wald χ² = 12.58; Exp(B) 95% confidence interval [CI] = 0.45–0.79; p < 0.001).

Table 3.

Factors Predicting Unmet Health Care Needs for Autistic LGBTQ+ Persons

	χ2	β	SE	95% CI	p
No. of laws prohibiting discrimination	12.583	−0.519	0.146	−0.806 to −0.232	<0.001
<100% FPL	5.662	−0.681	0.286	−1.241 to −0.120	0.017

χ², Wald χ² statistic; CI, confidence interval.

Furthermore, people living below the FPL were 0.51 times less likely to have unmet health care needs (Wald χ² = 5.66; Exp(B) 95% CI = 0.29–0.89; p = 0.017).

Discussion

Although research emphasizes the importance of investigating the health care experiences of autistic/LGBTQ+ people,^13,23 few studies have done so. Our study adds to the literature by examining differences in health status and unmet health care needs by comparing autistic/straight/cisgender people with autistic/LGBTQ+ people. Findings from this study suggest dual identities of LGBTQ+ and autistic may result in greater disparities in physical and mental health as well as unmet health care needs.

Since our study compared the health status and health care needs of both autistic/straight/cisgender people and autistic/LGBTQ+ people, this means the additive effect of an LGBTQ+ identity likely magnified these disparities. These findings align with LGBTQ+ literature describing a myriad of disparities in health care access as well as poorer mental and physical health status.^35,43,44 Our findings also align with other studies suggesting that the experience of dual identities (LGBTQ+ and autistic) can negatively impact health care access and mental health.^32–34

There were also significant differences between the straight/cisgender and the LGBTQ+ group on the total number of reported disabilities. Specifically, the LGBTQ+ group reported more co-occurring disabilities, especially co-occurring mental health conditions. This finding aligns with other studies that also reported increased prevalence of mental health conditions in autistic/LGBTQ+ people. Furthermore, a recent qualitative study reported that autistic transgender youth were frequently misgendered or deadnamed by their physician, which often led to fewer referrals to appropriate LGBTQ+ services and a decline in mental health.⁴⁵

Our finding suggests that autistic/LGBTQ+ people may have more health care needs due to more co-occurring conditions but have fewer of these needs met. Overall, given the higher prevalence of autistic people identifying as LGBTQ+ compared with the general population, the health and health care disparities evidenced by our study are critical areas to address to close this gap.

For our second research question, we examined how state health care policies and demographics associated with health care inequities predicted the unmet health care needs of the autistic/LGBTQ+ group. Results suggested that residing in states with health care laws prohibiting discrimination based on gender identity/expression and sexual orientation predicted fewer unmet health care needs for LGBTQ+ people.

Although a small sample, this finding could mean that a lack of equity-oriented state health care policies is associated with unmet health care needs among autistic/LGBTQ+ people. Specifically, equity-oriented state-wide policies prohibiting discrimination against LGBTQ+ people may act as one potential protective factor for unmet health care needs. Furthermore, living below the FPL was also a significant predictor of fewer unmet health care needs. This finding is contrary to some literature that reports living in poverty typically leads to worse access to health care and greater health care disparities, especially for those with disabilities.⁴⁶

However, our findings could mean that living below the FPL allowed access to comprehensive health insurance coverage through public assistance programs such as Medicaid. For example, people living above the FPL may no longer qualify for Medicaid, but may not have an income to receive comprehensive health insurance coverage. A recent report indicated that costs for people receiving Medicaid would increase by 25% if they were receiving job-based health insurance.

In addition, of the 51 autistic/LGBTQ+ people included in our second analysis, 23 had Medicaid coverage and the majority (n = 19) lived in an expansion state (i.e., a state that expanded Medicaid coverage by increasing eligibility to adults with incomes below 138% FPL).⁴⁷ Research suggests that Medicaid expansion is associated with increased health insurance coverage, access to health care services and medications, affordability, and having personal doctors.^47–49 Overall, this could mean that greater insurance coverage, regardless of income, results in better access to health care services and fewer unmet needs.

However, this finding deserves caution, and replication in future studies is necessary to examine the nuances of this finding. Future research also should conduct a similar analysis with a more diverse sample and use a social determinants of health perspective to examine how multiple levels (i.e., national, state, county, community, and person levels) of disparity drivers affect the unmet health care needs as well as health care experiences of autistic/LGBTQ+ people.⁵⁰

Furthermore, we were unable to include race, ethnicity, and residing in a rural area in our model since our sample lacked diversity, and future studies need to investigate the intersection of these characteristics with an autistic LGBTQ+ identity. Understanding the ways current structural factors facilitate or create barriers related to health care access is important for future policy development to ameliorate disparities.

Limitations and future directions

Although our study included a national sample, with over-representation of people identifying as LGBTQ+, the subsample of autistic adults was still relatively small, lacked racial and ethnic diversity, and did not include a nonautistic and/or nondisabled comparison group. Since research points to inequities for marginalized racial and ethnic groups in both autism and LGBTQ+ research,^13,51,52 it is critical to understand whether there are differences in the health care experiences among marginalized racial and ethnic groups who have the additional identities of autistic and LGBTQ+.

Furthermore, our variables related to state health care laws that prohibit discrimination against gender/identity or sexual orientation were significant predictors of unmet health care needs for the LGBTQ+ group. However, there are likely additional predictors (e.g., provider knowledge, cultural factors, community factors, social factors, and cohort/time effects) or mediating variables that may explain more of the variance in total unmet health care needs. In addition, our survey only included one question on gender identity, which means our sample may have missed transgender/binary people.

Future studies should ask two questions to determine gender identity, one question about sex assigned at birth and a second question on gender identity. Last, the survey's gender identity question used the term “other” to identify nonbinary gender identities, which is noninclusive language. Future studies should list more gender identities and use “none of the above, please specify” options as alternative verbiage to “other.”

Future research should examine additional structural variables that may provide insight into the increased number of unmet health care needs. For example, research should examine how systems of care, provider knowledge, public assistance programs, and Medicaid expansion supported access to health care for autistic/LGBTQ+ people living below the FPL, as well as the barriers that continue to exist. Furthermore, studies have suggested that many health care providers lack knowledge and training related to LGBTQ+ health care needs,^53,54 and this is especially true for people with dual identities of LGBTQ+ and autism, as providers often specialize in only one of these areas of practice.⁴⁵

This situation means that the health care needs of people with intersectional identities may go unnoticed or may be dismissed. Research suggests that disparities in health care for people identifying as LGBTQ+ may be driven by provider biases.⁵³ Thus, provider biases, provider knowledge, and the number of providers specializing in both autism and LGBTQ+ health are worthy of further exploration to address the unmet health care needs of autistic/LGBTQ+ people.⁵⁵

In addition, using community-partnered participatory research models may help to support ongoing collaboration with autistic/LGBTQ+ people throughout the research process.⁵⁶ Community-partnered participatory research models are specifically used to decrease disparities among stakeholders, and by actively partnering with autistic stakeholders, we may help to devise research questions, research procedures, findings, and policies that aim to decrease health care gaps specific to autistic/LGBTQ+ people. Furthermore, understanding the perspectives of autistic LGBTQ+ people also will elucidate the interpersonal barriers and facilitators that may be associated with their unmet health care needs.

Recent literature has indicated a heightened risk for suicide among autistic youth and adults, with up to 66% of autistic people experiencing suicidal ideation.⁵⁷ Given that identifying as LGBTQ+ alone increases risk for suicide,^35,36 the dual identities of autism and LGBTQ+ may exacerbate suicide risk. Relatedly, we found that autistic LGBTQ+ people reported significantly more poor mental health days than the autistic/straight/cisgender group. Thus, future research should examine whether there is a heightened suicide risk for autistic/LGBTQ+ people to develop suicide prevention strategies, and other mental health supports, for people with dual identities.

Overall, fewer studies exist aiming to understand autistic/LGBTQ+ people; yet there are clearly additional areas that must be studied to lessen disparities for this multiply-marginalized group and improve their health care experiences and access.

Authorship Confirmation Statement

A.W. and B.A.B. conceptualized the idea and outlined the article. J.P.H. and N.K.K. created the national survey and collected data. A.W. conducted the data analysis and N.K.K. checked the results. A.W. drafted the article and all additional authors (B.A.B., J.P.H., N.K.K., C.G.S., A.M., D.J.M., and K.B) provided substantial feedback for the final draft.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The National Survey on Health and Disability (NSHD) is administered by the University of Kansas Institute for Health & Disability Policy Studies (KU-IHDPS) and funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR project nos.: 90DP0075-01-00 and 90IFRE0050-01-01). The contents of this article do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the federal government.