Exploring healthcare access among lesbian, gay, bisexual, and transgender populations in Orange County, California: A pilot cross-sectional study

Abstract

There are approximately 90,000 lesbian, gay, bisexual and transgender (LGBT) individuals in Orange County, California. LGBT individuals have significant health disparities, particularly if they are from racial or ethnic minority groups and/or have a disability. There are structural and access barriers in the healthcare system that increase these health disparities. These individuals experience discriminatory situations when accessing healthcare and mental health services, which may affect their health-seeking behaviors. The purpose of this pilot quantitative cross-sectional study was to gather information about the current healthcare experiences and needs of this LGBT population including priority health issues, physical and mental healthcare utilization, and perceived adequacy of LGBT-friendly physical and mental healthcare providers. These findings will inform organizational strategies for nursing administrators and other healthcare leaders when tailoring, planning, and redesigning structures that meaningfully address the service needs of this at-risk group. Seventy-five participants were recruited from two organizations serving the LGBT community to complete an online survey. Findings include trouble finding an LGBT competent provider, delays or being unable to access care, worried about losing insurance. Most participants needed to visit multiple different locations to receive care and preferred a one-stop shop.

INTRODUCTION AND BACKGROUND

There are an estimated 90,000 lesbian, gay, bisexual, and transgender (LGBT) individuals over the age of 14 in Orange County, California¹. LGBT individuals often experience adverse situations when accessing healthcare and mental health services, including fear, stigma, invidious discrimination, homophobia, and violence perpetrated by healthcare providers^2–4. Access is defined as the ability to seek healthcare services, to reach the healthcare sites and resources, to obtain or use health care services, and to be offered services by providers that are appropriate to meet the needs of individual patients^5,6.

LGBT populations are known to have significant health disparities,^8,9 especially if they are from minority racial and/or ethnic groups or have a disability¹⁰. Compared to cisgender, heterosexual counterparts, LGBT populations have disproportionate rates of new HIV infections, sexually transmitted infections, cigarette smoking, substance use, adverse childhood experiences (ACE), depression, suicidality, completed suicides, and other mental health issues^10–12 so having improved access to appropriate quality healthcare and mental health care services is of paramount importance for optimal health outcomes. Eliminating LGBT health disparities and enhancing efforts to improve LGBT health are critical to ensuring health equity for all people to lead long, productive healthy lives¹³.

According to the National Academy of Medicine, there is limited data on the health needs and healthcare utilization patterns of LGBT individuals⁸. Healthy People 2030 calls for increased demographic and epidemiological research that focuses on social challenges and healthcare inequalities such as discrimination, stress, and the specific health needs for LGBT populations, particularly adolescents and young adults¹⁴.

To improve healthcare access, the United States Department of Health and Human Services’ set a goal to end the HIV epidemic by 2030¹⁵. Ending the HIV Epidemic in the U.S. (EHE) focuses first on 50 local areas that account for more than half of new HIV diagnoses and Orange County, California is on the list of priority jurisdictions. President Biden recently requested an additional 670 million dollars to expedite this goal to 2025, further underscoring the need to improve the health, safety, and wellbeing of LGBT individuals¹⁶. One hundred and seventy million of this funding was allocated to Ryan White HIV/AIDS Programs, community clinics that work with LGBT, racial minority, low income, and other underserved populations to provide a wide range of services, including healthcare access and case management¹⁶.

This pilot study is the first known of its kind that examines physical and mental healthcare experiences of LGBT individuals in Orange County, California. In Orange County, the only current data solely relates to HIV incidence and prevalence rates⁸. The information from this small, exploratory pilot study will address a gap in information that is not currently available, as well as inform nursing administrators and other healthcare leaders on effective strategies to meet the needs of this population as they work towards improving healthcare quality and service delivery. This study is also unique because we used a community-based participatory research (CBPR) approach in partnership with two LGBT organizations who have been instrumental in all aspects of the project development providing an invaluable perspective.

SPECIFIC AIMS

The specific aims of this pilot project were to: (a) explore and report the current experiences and healthcare needs of LGBT individuals (including physical and mental healthcare utilization patterns, locations, and perceived adequacy of LGBT-friendly healthcare providers), (b) characterize priority health issues, and (c) identify perceived barriers and gaps in available medical and mental health services for LGBT populations in Orange County, California. Findings from this study will assist nursing administrators and other healthcare leaders with developing tailored evidence-informed solutions to improve access and quality of care for members of the LGBT community.

Nursing administrators and other healthcare leaders in all settings will encounter individuals from the LGBT community and the information obtained from this study will provide an evidence informed understanding of the challenges experienced by the LGBT community when accessing healthcare and mental health services. Findings will inform the development of evidence-based institutional policies, clinical practices, standards of care, and policy priorities within your institution or organization. There are also opportunities to inform research and educational priorities about these issues to improve treatment, care, and services for the LGBT community in your region.

METHODS

Design.

This cross-sectional study used a convenience sample from two LGBT organizations. One organization provides mental health services and the other one, formerly an AIDS service organization, is now providing more comprehensive healthcare and social support services to the LGBT community including HIV & STI testing, case management, food pantry, and mental health counseling. A 45-question online survey was created using Qualtrics (Provo, UT) and sent to all active adult patients (age ≥ 18 years) at the two organizations by email. Individuals who elected to participate completed informed consent. There were thirteen demographic questions, seventeen care access questions, fifteen care experience questions, as well as two optional questions to sign-up for $50 raffle drawing and/or future focus group. Participants were queried about priority health issues, finding healthcare services and providers, barriers to receiving healthcare services, and healthcare experiences. We assessed their level of comfort with their provider and provider sensitivity and knowledge around LGBT health issues using a Likert-type scale, with responses ranging from “extremely” to “not at all”. The survey data collection period occurred between January 2020 and April 2021.

Data Analysis.

Responses to survey questions about priority physical and mental health issues, participant experiences with healthcare services and providers (including difficulty finding a provider, being refused services, healthcare delays, comfort with providers, and adverse situations with providers), and barriers to healthcare access were summarized using descriptive statistics. Overall frequency distributions were calculated for each response, as well as across race/ethnicity, gender identity, sexual orientation, and income categories. Analyses were completed using Stata 14 (College Station, TX).

RESULTS

A total of 75 LGBT self-selected participants completed the study (see Table 1). Most of the participants were assigned male sex at birth 57% (n = 43). There was an almost equal number of White 49% (n = 36) and non-White 50.3% (n = 37) participants. Most of the non-White participants were of Latino/Hispanic descent and identified as gay 48% (n = 36) or bisexual 28% (n = 21). Overall, 53% of participants (n = 39) were partnered and 43% (n=32) had at least a bachelor’s degree. In terms of household income, there were similar numbers of participants making under $34,000 annually 52% (n = 39) and those making over $34,000 48% (n = 36).

Table 1.

Participant Sociodemographic characteristics (n=75)

	n	%
Race
White/of European descent (non-Hispanic)	36	49
Non-White/Other	37	50
Sex Assigned at Birth
Male	43	57
Female	29	39
Intersex	1	1
Gender Identity
Male	41	55
Female	22	29
Transgender, Nonbinary, Intersex, Genderfluid	12	16
Sexual Orientation
Gay	36	48
Bisexual	21	28
Lesbian	9	12
Heterosexual	6	8
Asexual	3	4
Relationship Status
Single/Divorced/Widowed	35	47
Partnered	39	52
Household Income
Under $34,000	39	52
Over $34,000	36	48
Education Level
High school or less	23	31
Associates Degree/Vocational School/Professional Certificate	20	27
Bachelor’s degree or greater	32	43

Priority Health Issues Identified

Physical Health

Body weight was most frequently ranked as a top physical health concern (n = 39). However, the statistically significant findings overall were regarding HIV/AIDS (n = 38, Fisher 0.001)). Cancer was a chief concern among a third of participants (n = 26). The fourth most reported concern was heart disease (n = 24). Finally, erectile or other sexual dysfunctions were identified (n = 19) as the fifth priority physical health concern,

Mental Health

Depression/thoughts of suicide was most frequently identified (n = 40) as a priority mental health issue. A third of participants (n = 26) identified other mental health concerns as problematic or disturbing. Body image (n = 24), substance use/street drug use/prescription drug use (n = 17) were significant mental health concerns identified by participants. Lastly, alcohol use (n = 10) was the fifth mental health concern.

Healthcare Services and Providers

In our sample, 89% (n = 67) of participants had a place they usually went to in Orange County to access physical healthcare services. Almost half, 49%, (n = 35) of all participants reported trouble finding a physical healthcare provider in the last 12 months who would see them for a health issue (see Figure 1), however, of those, 96% (n = 69) of participants indicated they were ultimately able to find the physical healthcare services they needed. Of individuals making less than $34,000, 61% (n = 22) reported trouble finding a healthcare provider. Similarly, 67% (n = 8) of transgender/nonbinary/intersex/genderfluid participants, had difficulty finding a healthcare provider. This is a noteworthy finding, even with our small sample size. Thirty-four percent of non-White participants (n = 12) reported being refused services by a physical or mental healthcare provider.

Figure 1.

Healthcare Services and Providers

Overall, 78% (n = 56) of participants reported being able to find the mental health services that they needed and 75% (n = 54) had a place where they usually accessed mental health services. In the total sample, 22% (n = 21) were not able to find mental health services; sub-group analyses identified that 40% of bisexuals (n = 8) and 33% of non-White (n=12) were not able to find mental health services they needed.

Healthcare Delays and Concerns.

Forty-four percent of all participants (n = 32) experienced delays in getting medical care, tests, or treatments that they or their healthcare provider believed were necessary. Those who experienced delays in getting medical care, tests, and treatments they believed were necessary were transgender/nonbinary/intersex/genderfluid (n = 7), bisexuals (n = 11), and those earning less than $34,000 annually (n = 19).

In the past 12 months, 36% (n = 26) of all participants and 52% (n = 11) of females, were unable to obtain medical care, tests, or treatments that they or their healthcare provider believed were necessary. Sixty percent of bisexual participants (n = 12) identified needing to see a physical health or mental health provider but could not because they didn’t have enough money.

Level of Comfort, Sensitivity, and Knowledge of Providers.

Forty-three percent of all participants (n = 32) indicated they were “somewhat comfortable” in the waiting rooms of their physical or mental healthcare providers, with 39% (n = 29) indicating they were “extremely comfortable”. The majority of participants 51% (n = 38) indicated that their physical healthcare providers were “somewhat sensitive” to their needs as LGBT individuals (see Figure 2). Significant to note, among transgender/nonbinary/intersex/genderfluid individuals, none indicated that their provider was “extremely sensitive”. However, overall, participants rated their mental health providers as more sensitive than their physical health providers. Mental healthcare providers were more frequently rated “extremely sensitive” at 31% (n = 23), compared to 16% (n = 21) of physical health providers.

Figure 2.

Sensitivity and Knowledge of Providers

Over half of the participants 51% (n = 38) thought that their providers were “somewhat knowledgeable” about LGBT issues that impacted them, with no transgender/nonbinary/intersex/genderfluid participants indicating that their providers were extremely knowledgeable. Overall, 39% (n = 29) of participants were “somewhat comfortable” talking to their healthcare or mental health provider about personal aspects of their lives such as sexual orientation, gender identity, HIV status, sexual behaviors.

Adverse Situations.

When participants were asked if they had ever experienced or felt they had experienced any adverse situations with a healthcare provider in the last 12 months, most participants identified “no adverse situations” (n = 33) among physical healthcare providers. However, where occurrences were reported, neglect (n = 17), mistreatment (n = 15) and homophobia (n = 13) were identified. For mental health providers, the majority of participants (n = 41) reported “no adverse situations”. Of those who did report negative experiences, there were less frequent occurrences of neglect (n = 13), mistreatment (n = 8), and homophobia (n = 9) than physical health providers. These are frequencies and not percentages of individuals since these responses were not mutually exclusive and participants were allowed to mark all that apply.

Healthcare Access Barriers

Provider Competency and Financial Cost.

When asked the mark-all-that-apply question, what are your barriers to accessing healthcare and/or mental health services, the top two responses identified had similar frequencies: unsure which providers are LGBT competent (n = 35) and financial cost (n = 34).

Having to Go to Multiple Locations.

Another barrier identified was having to go to multiple different locations across the county to have all their healthcare/mental healthcare needs met (n = 51, 68.0%). Overwhelmingly, the participants were in favor of a “one-stop shop” (n = 62, 82.7%), which refers to a single convenient location where they could get all of their medical, mental health, dental, case management, food pantry, and health education services.

Anticipatory Concerns about Healthcare Coverage.

Almost all our participants (n = 68, 94%) reported currently having health insurance, however, 36% (n = 13) of non-White participants were uninsured or had no coverage at some point in the previous 12 months. Over half of all participants (n = 44, 61.1%) identified that they were worried about losing or not having access to health insurance. Among those earning less than $34,000 annually, 72% (n = 26) had this concern. About a third of participants (n = 26, 34.7%) needed to see a healthcare or mental healthcare provider but could not because they did not have enough money.

Discussion

The major physical health issues identified by the participants in Orange County, California were close in frequency between body weight and HIV/AIDS. In terms of mental health, there were substantial findings for depression/thoughts of suicide and other mental health concerns. There is an opportunity for providing additional access related to health and mental health services for LGBT individuals who need these services. Particularly, when you think about this against the backdrop of having providers who are sensitive and knowledgeable about issues specific to the LGBT community.

There were a few issues related to nursing administrators and other healthcare leaders that were identified in this study. Nearly half of participants identified they had trouble finding a healthcare provider who would see them. This issue is compounded by participants not being aware of which physical or mental healthcare providers are culturally competent and /or informed by evidence-based knowledge to provide appropriate health or mental health services to meet their specific needs. These uncertainties around providers contribute to participants experiencing delays and being unable to get the care that they or their providers thought were necessary^2,12. LGBT individuals may perceive an inability to receive care from healthcare providers that are sensitive to their needs^8,12. This uncertainty can further increase barriers to access, quality, and timeliness of care, which contribute to health disparities experienced by LGBT individuals. Having known LGBT sensitive and knowledgeable providers in all settings may help minimize negative healthcare experiences and facilitate better healthcare engagement among this population^12,17,18.

Some participants did report adverse situations, such as neglect, mistreatment, and homophobia by their provider, in the past year. Of participants who reported adverse situations, fewer of these experiences were reported with mental health providers. Despite this, these past occurrences may still contribute to anticipatory concerns when this population seeks out the care of both physical and mental healthcare providers in the future¹².

Over half of the participants identified being worried about losing or not having insurance. Similarly, money was of concern for about a third of the participants, in the previous 12 months, when it came to choosing whether to visit a physical or mental health provider¹⁸. Both anticipatory concerns may have contributed to a lack of access for our LGBT participants. Bowling et al.¹⁷also cited a lack of personal financial resources as a top perceived barrier to being able to access healthcare which then caused LGBT individuals to resort to other alternatives to receive their routine healthcare services, including using emergency departments for mental health and other healthcare needs^6,19.

Participants identified having to go to multiple locations to have all their healthcare needs met. This lack of access to a single, all-encompassing site for LGBT health creates an unnecessary transportation issue, which is a barrier to receiving comprehensive care. Therefore, the idea of a “one-stop shop” would be very beneficial to the LGBT community in Orange County, California. There are already comprehensive LGBT care centers available in California, such as AIDS Project, Los Angeles (APLA) and Desert AIDS Project in Palm Springs, that provide both physical and mental healthcare services, case management, behavioral health education, benefits eligibility, and social services (housing, transportation, food).

There are several limitations that we recognize in this pilot study. Recruitment was postponed for approximately nine months because of the COVID-19 pandemic which started in March 2020. Because of our convenience sampling and cross-sectional study design, our data cannot be generalizable to a larger population. Also, this convenient sampling of participants were recruited from two sites that currently offer services to the LGBT community, thus the insights of those outside this system of care were not captured.

Next steps.

Further exploration through focus groups is needed to determine why subgroups of the sample (i.e., non-White and transgender groups) in this study reported greater challenges with accessing mental health services and were refused services they thought were needed^6,10. In addition, future survey tools would need to include a comment box to allow participants to describe what was meant by providers who are somewhat sensitive and somewhat knowledgeable. However, we think that these findings are valuable for identifying and addressing priority health needs for this location and contribute to the larger body of knowledge about LGBT health in the region. It also serves to inform larger studies that will further be able to investigate the health and mental health needs of LGBT populations nationwide.

In our analyses, we realized that there were some additional questions we could have asked to provide greater insight into healthcare challenges for this population, especially since mental health issues were noted to be a top priority issue for our participants. Firstly, we did not ask about specific mental health symptoms or disorders such as anxiety, depression, trauma, poor sleep, or substance use, etc., which we believe could have been commonly reported mental health concerns. Secondly, we did not provide the participants with a comment box to tell us what their other mental health concerns were. Therefore, we were not sure what other mental health issues may have been of concern to this community. In future studies, we are going to be focusing more on mental health concerns and access to treatment that is appropriate.

Implications for Nursing Administrators and healthcare leaders

When considering best methods for tailoring approaches to engage LGBT groups, it is important for nursing administrators and healthcare leaders to create a welcoming environment that promotes psychological safety. This would include showcasing educational materials about LGBT health, openly displaying an organizational nondiscrimination policy, and advertising posters of non-profit LGBT organizations and resources in common patient areas²⁰.

Nurse leaders need to be intentional in implementing inclusive excellence education for all healthcare and non-healthcare staff about sexual and gender diversity and intentional behaviors that provide gender affirming and family centered care, such as acknowledgment and use of patient preferred pronouns²¹. Nursing administrators can develop and/or tailor resources for awareness training for staff to focus on treating all patients with respect with the goal of decreasing stigma, bias, bullying, and suicide prevention with a special focus on minoritized LGBT populations²¹.

Content on LGBT health in nursing curricula, especially on the unique needs of transgender/nonbinary/intersex/genderfluid people, are minimal at best. There’s some literature out there about how providers want to care for gender diverse people but do not know how or feel that they did not receive adequate training. It is imperative that healthcare providers possess cultural humility and clinical knowledge regarding the health care needs of LGBT groups. It is the responsibly of nursing administrators and other nurse leaders to support the development, implementation, and evaluation of practices and policies that support protection against invidious discrimination and other bias and stigmatized care of LGBT people in their places of healthcare delivery.

These activities must be supported by nursing administrators and other nurse leaders in the way they allocate organizational resources including their budgets, personnel, and other assets and can be measured using numerous methods including making these skills a part of the employee performance evaluation. To meet these goals, priority interventions should include developing trainings to increase provider clinical competence, level of comfort, and patient acceptance when treating this population.

Nurse leaders have an opportunity to develop training to help LGBT patients become comfortable and safe revealing their sexual and gender orientation to providers so that the best treatment options can be provided. Lastly, nursing administrators and healthcare leaders can ensure office and institutional practices that are consistent with gender and sexual affirming standards of care. The development of inclusive institutional clinical practices from patient intake to implementation of evidence-based treatments conforms to quality standards for mental and physical care service delivery.

Conclusion

No known research until now has characterized priority health issues and explored LGBT access to healthcare in Orange County, California. For nursing leaders, understanding the healthcare experiences of LGBT individuals and the barriers they face when accessing healthcare informs effective solutions that can improve access and quality of care for members of the LGBT community in Orange County, California and beyond. Priority physical and mental health challenges, notably body image, HIV/AIDS, cancer, depression, and substance use were identified, which suggest that more vital work needs to be done with this population in these critical health areas. It also highlights the need nursing administrators and healthcare leaders to support the delivery of evidence-based and culturally competent services to help mitigate these issues in the LGBT population.

Optimal health for LGBT populations can be facilitated by increasing access to healthcare and mental health services, creating a welcoming clinical environment, and by developing LGBT sensitive and knowledgeable physical and mental healthcare providers. Welcoming healthcare environments facilitate ease and comfort of LGBT individuals to disclose their medical and mental health history, sexual orientation and matters of their sexual identity, sexual behavior, sexual attractions, and healthcare needs. Having providers who are accessible and who understand the specific needs of each subgroup of the LGBT population would be invaluable so that appropriate care can be rendered. Kameg et al²² suggests that health care organizations should ensure access to sensitivity and humility training for all nurses and providers so that they have the necessary knowledge to provide competent care to the LGBT population.

Using CBPR approaches, nursing administrators and healthcare leaders can also develop new strategies in partnership with outside organizations and individuals who have “lived experiences” of neglect and mistreatment to better understand the challenges around health-seeking behaviors, and what interventions are needed to promote a welcoming environment. Partnering with community stakeholders on processes and strategies to address these issues will foster trust to enable the development of meaningful solutions that can adequately address health disparities for LGBT communities to ultimately improve access to quality health care and mental health care services.

Thinking about this data in relationship with the social determinants of health, with LGBT people being concerned about finances and insurance access, they will not prioritize healthcare if they have other more important competing priorities, such as housing or food. If we are going to end the HIV epidemic in Orange County, California, it will require a multi-faceted holistic approaches to address the issues that are impacting ease of access to health care and mental health care services.