Abstract
Purpose: Prior studies have identified health care providers' lack of cultural competency as a major barrier to care among sexual minority individuals. However, little is known about disparities in experience with culturally competent care by sexual orientation at the population level. This study assessed experiences with culturally competent care and satisfaction with care across sexual orientation groups in the United States.
Methods: We analyzed nationally representative data from the 2017 National Health Interview Survey (n = 21,620) with ordinal logit regression models and compared six aspects of health care experiences across sexual orientation groups. These were: preferences for and frequencies of seeing health care providers who understand or share their culture; perceived experiences of being treated with respect by providers and providers asking about their beliefs and opinions; access to easily understood health information from providers; and satisfaction with received care.
Results: Relative to heterosexual men, gay men were more likely to consider it important for providers to understand or share their culture (odds ratio [OR] = 1.4, p < 0.05) and to have providers who ask for their opinions or beliefs about care (OR = 1.5, p < 0.01). Relative to heterosexual women, bisexual- and something else-identified women were less likely to report being treated with respect (ORs = 0.4–0.6, p's < 0.01) and satisfaction with care (ORs = 0.5–0.6, p's < 0.05). No statistical differences in health care experiences were found between other sexual minority groups and their heterosexual counterparts.
Conclusions: Access to culturally competent care and satisfaction with care varied by sexual orientation and gender. Clinical practices should address the unique health care barriers faced by bisexual- and something else-identified women.
Keywords: barriers to care, cultural competency, health service delivery, sexual minority
Introduction
It is widely acknowledged that sexual minority individuals, including lesbian, gay, and bisexual (LGB) individuals, experience poorer access to and utilization of health care services than heterosexual individuals.1–5 For example, sexual minority individuals are more likely to experience delayed care or unmet care needs, skip preventive checkups, and not use a regular health care provider.1,5 Although previous studies have indicated that labor market discrimination based on sexual orientation, legal restriction on same-sex marriage, unemployment and poverty, and, consequently, a lack of insurance coverage are important contributors to lower access to health services among sexual minority individuals,3–5 some studies have also noted that health care disparities by sexual orientation persist even after adjusting for economic factors and when insurance rates become increasingly similar among LGB and heterosexual individuals.2,6,7
Health care providers' lack of cultural competency—the sensitivity, knowledge, and skills to understand and respond to the unique health needs, beliefs, and practices of diverse patients—is a major barrier to care among sexual minority populations.8,9 Prior studies, largely based on qualitative data, have suggested that sexual minority individuals may underutilize health services and feel dissatisfied with the care they receive due to providers' low competency.10–12 In particular, heterosexual providers' implicit and explicit preferences for heterosexual individuals over gay or lesbian individuals are pervasive.13 Heterosexual providers' presumptions that all patients are heterosexual tend to discourage sexual minority patients from disclosing their sexual orientation in clinical encounters, foster a sense of discomfort and distrust among patients, compromise patient–physician communication, and thus reduce patients' opportunities to receive relevant health information and appropriate treatment.10–12 Due to a shortage of sexuality-inclusive training for employees and trainees within health care organizations,9,14 the fear of stigmatization, denied services, and mistreatment by providers continue to be critical health care concerns for many sexual minority individuals.15
Although qualitative research has previously explored the role of providers' cultural competency in health care experiences among sexual minority patients, little is known about the extent to which sexual minority patients receive less competent care in comparison to heterosexual patients at the population level. Moreover, due to small sample size, prior research has not fully examined gender differences in the experience of culturally competent care. In the past three decades, much of the research and funding related to the health care of sexual minority individuals has focused on HIV/AIDS among men.10 As a result, it is unclear whether sexual minority women receive less or more culturally competent care compared with sexual minority men. Our study addresses these knowledge gaps. We used nationally representative data from the 2017 National Health Interview Survey (NHIS) to examine patients' preferences for and frequencies of seeing health care providers who understand or share their culture, perceived experiences of being treated with respect by providers and providers asking about their beliefs and opinions, access to easily understood health information from providers, and satisfaction with received health care across sexual minority and heterosexual populations. Our findings may inform practices and policies to lower health care barriers faced by specific sexual minority groups.
Methods
Data and sample
The study used data from the 2017 NHIS prepared by the IPUMS NHIS.16 The NHIS is an annual household survey conducted by the National Center for Health Statistics on a broad range of health topics, including health care access and utilization. The survey collects information from nationally representative samples of the civilian noninstitutionalized U.S. population. In 2017, a set of supplementary questions on the cultural competency of health care providers, funded by the Centers for Disease Control and Prevention's Office of Minority Health and Health Equity, was added to the sample adult questionnaire. Our analysis is based on the sample of adult respondents aged 18 and older who have seen a health care provider in the past 12 months; see Supplementary Table S1 for eligibility by sexual orientation and gender. Our final sample (n = 21,620) excludes those who have not seen a provider in the past 12 months (n = 3878) and those missing information on any covariates (n = 1244) except family income. In the final sample, 96.3% were heterosexual; 1.9% were gay or lesbian; 1.3% were bisexual; and 0.5% identified as something else.
Because about 15% of the cases lacked information for the family income variable, we performed multiple imputations by using the NHIS-imputed income files to generate income values for these cases. This study was exempt from review by the institutional review board of Michigan State University, as it did not involve interaction with human subjects and used a publicly available de-identified dataset.
Measures
We examined health care experiences by using six variables that assessed preferences for and perceived experiences of culturally competent care and satisfaction with care received in the past 12 months. All of these variables were rated on a 4-point scale. Importance for providers to understand/share culture indicates how important it is to the respondent that health care providers understand or are similar to the respondent regarding cultural aspects such as race, ethnicity, gender, religion, beliefs, and native language (1 = not important at all, 2 = slightly important, 3 = somewhat important, 4 = very important).
Frequency of seeing providers who share culture indicates how often the respondent was able to see health care providers who are similar in any of the cultural aspects. This item was only asked of respondents who previously expressed that it is slightly, somewhat, or very important for health care providers to understand/share their culture. Frequency of being treated with respect by providers indicates how often the respondent perceived being treated with respect by their health care providers. Frequency of providers asking for opinions/beliefs about care indicates how often health care providers asked for the respondent's opinions or beliefs about the medical care or treatment, such as what kind of tests, procedures, or medications the respondent prefers. Frequency of providers giving easy-to-understand information indicates how often health care providers told or gave the respondent information about their/his/her health and health care that was easy to understand. All items used the same frequency scale (1 = none of the time, 2 = some of the time, 3 = most of the time, 4 = always). Finally, satisfaction with care indicates the level of satisfaction with the health care received in the past 12 months (1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = somewhat satisfied, 4 = very satisfied).
Sexual orientation was assessed with a question about the respondent's sexual identity and included the following four categories: lesbian or gay; straight, that is, not lesbian or gay; bisexual; something else. Although the original survey questions included an additional response category “I don't know the answer,” we excluded this group from our analysis because of its ambiguity and prior research with NHIS data that suggested the majority of this group does not identify as sexual minority individuals.17
We adjusted for the following sociodemographic characteristics in the regression analysis: age (in years), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, or non-Hispanic other), marital status (married, cohabiting, never married, or previously married), family income (in $1000), education (less than high school, high school diploma or general educational development, some college, or bachelor's degree or above), and region of residence (Northeast, Midwest, South, or West). These covariates may independently or jointly shape the respondents' perceived importance of, access to, and experiences of culturally competent care as well as their levels of satisfaction with received care. Most notably, less educated and racial/ethnic minority groups may rate their health care experiences differently due to being dismissed and poorly treated by providers and/or response differences (e.g., tendency of selecting more extreme options).18–20
Statistical analyses
We first used descriptive statistics to summarize all variables by sexual orientation. We then used ordinal logit regression models to assess the relationship between sexual orientation and each of the six health care experience variables. These regression models included sociodemographic characteristics as control variables, and their results are presented as adjusted odds ratios (AORs). All of the descriptive and regression analyses were stratified by gender to assess whether sexual orientation differences in health care differed between men and women. We also formally tested the interaction between sexual minority status and gender by pooling samples for men and women in regression analyses. We adjusted all analyses to account for the multistage sampling design, oversampling on racial/ethnic minority individuals, nonresponse, and poststratification in the NHIS and conducted our analyses by using the svy and mi functions in STATA 15 (StataCorp LLC, College Station, TX). The analyses were performed in 2019–20.
Results
Table 1 presents the descriptive statistics of sociodemographic characteristics and health care experiences by sexual orientation among men. On average, sexual minority men, particularly bisexual and gay men, were significantly younger than heterosexual men. Note that this age gap may shape the distribution of other sociodemographic and health care variables. Moreover, sexual minority men were all significantly less likely to be currently married and more likely to be never married than heterosexual men. Average family income appeared much lower among men self-identified as bisexual or something else when compared with heterosexual men, although the difference did not reach statistical significance. Gay men, however, were significantly more likely to have a bachelor's or higher degree than heterosexual men. The descriptive results also suggest that most health care experiences did not vary by sexual orientation among men, except that gay men were more likely to experience providers asking for their opinions or beliefs about the medical care than heterosexual men.
Table 1.
Descriptive Statistics of Sociodemographic and Health Care Experience Variables by Sexual Identity Among Men, National Health Interview Survey 2017 (n = 9188)
| Variable | Heterosexual (n = 8844) |
Gay (n = 231) |
Bisexual (n = 71) |
Something else (n = 42) |
||||
|---|---|---|---|---|---|---|---|---|
| %/Mean | 95% CI | %/Mean | 95% CI | %/Mean | 95% CI | %/Mean | 95% CI | |
| Age (year) | 49.1 | 48.5–49.6 | 42.5 | 39.8–45.2 | 36.9 | 31.7–42.1 | 43.1 | 36.2–50.0 |
| Race/ethnicity | ||||||||
| Non-Hispanic White | 67.3 | 65.4–69.2 | 67.6 | 58.2–77.0 | 56.2 | 40.1–72.3 | 63.8 | 44.3–83.3 |
| Non-Hispanic Black | 10.8 | 9.7–11.9 | 8.4 | 2.4–14.5 | 6.7 | 1.1–12.4 | 20.9 | 5.7–36.3 |
| Hispanic | 14.2 | 12.6–15.9 | 17.3 | 10.8–23.8 | 23.0 | 8.7–37.2 | 7.0 | −1.5–15.5 |
| Non-Hispanic other | 7.6 | 6.7–8.5 | 6.7 | −0.1–13.5 | 14.1 | 2.5–25.7 | 8.2 | −1.0–17.3 |
| Marital status | ||||||||
| Married | 59.3 | 57.9–60.7 | 22.5 | 14.7–30.3 | 30.4 | 15.7–45.0 | 30.4 | 13.2–47.5 |
| Cohabitating | 6.7 | 6.0–7.4 | 25.2 | 17.3–33.0 | 6.1 | −1.3–13.4 | 3.1 | −3.0–9.2 |
| Never married | 20.8 | 19.5–22.1 | 44.3 | 36.7–51.9 | 55.4 | 39.9–70.9 | 50.2 | 32.1–68.4 |
| Previously married | 13.3 | 12.5–14.1 | 8.1 | 4.4–11.7 | 8.1 | 2.5–13.7 | 16.3 | 2.8–29.8 |
| Family income ($1000) | 85.6 | 83.2–88.0 | 80.7 | 70.1–91.2 | 76.9 | 52.0–101.7 | 55.9 | 26.4–85.4 |
| Education | ||||||||
| Less than high school | 10.8 | 9.8–11.7 | 3.4 | 0.8–5.9 | 3.5 | −0.9–7.9 | 9.7 | 0.0–19.2 |
| High school diploma or GED | 23.5 | 22.3–24.7 | 16.5 | 9.9–23.2 | 39.4 | 23.0–55.7 | 26.5 | 6.8–46.2 |
| Some college | 29.6 | 28.2–31.0 | 31.3 | 23.2–39.3 | 31.2 | 17.9–44.5 | 29.1 | 12.1–46.1 |
| Bachelor's degree or higher | 36.1 | 34.5–37.8 | 48.8 | 40.6–57.0 | 25.9 | 12.8–39.0 | 34.7 | 15.0–54.4 |
| Region | ||||||||
| Northeast | 18.0 | 16.2–19.8 | 17.6 | 11.3–23.8 | 14.5 | 5.4–23.6 | 12.8 | 1.9–23.6 |
| Midwest | 22.8 | 21.2–24.4 | 18.4 | 12.4–24.3 | 25.4 | 12.6–38.2 | 24.7 | 7.9–41.6 |
| South | 35.3 | 32.9–37.7 | 29.8 | 22.4–37.2 | 25.9 | 11.5–40.2 | 29.3 | 10.2–48.4 |
| West | 23.8 | 21.8–25.9 | 34.3 | 25.2–43.4 | 34.2 | 19.4–49.0 | 33.2 | 14.2–52.2 |
| Importance for providers to understand/share culture | ||||||||
| Not important at all | 55.3 | 53.7–56.9 | 50.1 | 41.5–58.8 | 57.9 | 42.2–73.5 | 43.6 | 24.9–62.3 |
| Slightly important | 9.8 | 9.0–10.6 | 11.1 | 6.6–15.5 | 11.3 | −2.1–24.7 | 8.3 | −1.6–18.2 |
| Somewhat important | 17.4 | 16.2–18.6 | 17.6 | 11.4–23.7 | 15.5 | 4.8–26.2 | 17.2 | 4.9–29.5 |
| Very important | 17.5 | 16.3–18.7 | 21.2 | 13.7–28.7 | 15.3 | 4.2–26.5 | 30.8 | 11.3–50.3 |
| Frequency of seeing providers who share culturea | ||||||||
| None of the time | 8.2 | 7.0–9.4 | 7.8 | 0.7–14.8 | 3.9 | −3.8–11.6 | 22.8 | −6.3–51.8 |
| Some of the time | 22.6 | 20.8–24.5 | 13.5 | 6.2–20.8 | 12.0 | 1.4–22.6 | 13.3 | −2.6–29.1 |
| Most of the time | 31.2 | 29.4–32.9 | 39.7 | 27.2–52.3 | 40.9 | 14.6–67.2 | 43.3 | 13.8–72.8 |
| Always | 38.0 | 35.9–40.1 | 39.0 | 25.6–52.5 | 43.2 | 16.2–70.3 | 20.7 | 1.0–40.6 |
| Frequency of being treated with respect by providers | ||||||||
| None of the time | 0.7 | 0.5–1.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 |
| Some of the time | 2.6 | 2.1–3.1 | 2.2 | 0.3–4.2 | 3.9 | −0.4–8.2 | 15.0 | −3.2–33.3 |
| Most of the time | 14.3 | 13.3–15.3 | 11.9 | 7.6–16.2 | 17.5 | 6.1–29 | 16.8 | 5.0–28.7 |
| Always | 82.4 | 81.2–83.6 | 85.8 | 81.0–90.7 | 78.6 | 66.6–90.5 | 68.1 | 49.8–86.4 |
| Frequency of providers asking opinions/beliefs about care | ||||||||
| None of the time | 23.1 | 21.8–24.4 | 15.2 | 9.6–20.8 | 27.1 | 12.0–42.1 | 12.9 | 2.3–23.4 |
| Some of the time | 19.7 | 18.6–20.8 | 17.0 | 11.3–22.7 | 17.2 | 8.4–26.1 | 25.3 | 9.9–40.8 |
| Most of the time | 21.5 | 20.4–22.6 | 27.1 | 20.7–33.4 | 23.7 | 9.2–38.3 | 33.9 | 14.2–53.6 |
| Always | 35.7 | 34.3–37.1 | 40.8 | 32.9–48.6 | 31.9 | 17.2–46.7 | 27.9 | 12.0–43.8 |
| Frequency of providers giving easy-to-understand information | ||||||||
| None of the time | 2.0 | 1.6–2.4 | 1.0 | −2.5–2.0 | 0.4 | −0.4–1.1 | 3.1 | −3.0–9,2 |
| Some of the time | 6.6 | 5.9–7.2 | 5.0 | 2.1–7.9 | 3.7 | −0.0–7.3 | 17.0 | −1.0–34.7 |
| Most of the time | 24.7 | 23.5–25.9 | 23.8 | 16.8–30.8 | 22.4 | 10.9–33.8 | 29.6 | 11.7–47.5 |
| Always | 66.8 | 65.4–68.1 | 70.2 | 63–77.5 | 73.6 | 61.5–85.7 | 50.3 | 31.6–69.0 |
| Satisfaction with care | ||||||||
| Very dissatisfied | 1.4 | 1.1–1.7 | 0.8 | −0.8–2.3 | 1.0 | −1.0–3.1 | 3.7 | −3.4–10.8 |
| Somewhat dissatisfied | 3.2 | 2.8–3.7 | 1.5 | −0.4–3.5 | 4.0 | −0.2–8.1 | 0.0 | 0.0 |
| Somewhat satisfied | 23.2 | 22.0–24.4 | 23.4 | 17.4–29.4 | 26.1 | 12.0–40.1 | 35.5 | 16.3–54.8 |
| Very satisfied | 72.2 | 70.9–73.5 | 74.3 | 67.8–80.8 | 68.9 | 54.4–83.4 | 60.8 | 41.6–80.0 |
The question was only asked of respondents who expressed that it is slightly, somewhat, or very important for health care providers to understand/share their culture, and thus the estimates are based on a subset of the sample (n = 3901).
CI, confidence interval; GED, general educational development; n, number of respondents.
Table 2 shows that sexual orientation differences in sociodemographic characteristics among women, particularly age, marital status, family income, and education, largely mirrored the patterns observed among men. However, unlike men, women exhibited more differences in experiencing culturally competent care across sexual orientation groups. In particular, bisexual and lesbian women reported seeing providers who share culture significantly less often than heterosexual women. Women self-identified as bisexual or something else also reported being treated with respect by providers less often than heterosexual women. In addition, bisexual women were significantly less satisfied with care received than heterosexual women.
Table 2.
Descriptive Statistics of Sociodemographic and Health Care Experience Variables by Sexual Identity Among Women, National Health Interview Survey 2017 (n = 12,432)
| Variable | Heterosexual (n = 11,981) |
Lesbian (n = 182) |
Bisexual (n = 207) |
Something else (n = 62) |
||||
|---|---|---|---|---|---|---|---|---|
| %/Mean | 95% CI | %/Mean | 95% CI | %/Mean | 95% CI | %/Mean | 95% CI | |
| Age (year) | 49.1 | 48.7–49.6 | 42.7 | 39.6–45.7 | 31.6 | 29.3–33.8 | 41.9 | 35.7–48.0 |
| Race/ethnicity | ||||||||
| Non-Hispanic White | 65.2 | 63.3–67.1 | 67.3 | 58–76.7 | 64.8 | 55.0–74.6 | 64.3 | 49.2–79.3 |
| Non-Hispanic Black | 12.4 | 11.1–13.7 | 12.6 | 5.5–19.8 | 14.7 | 5.8–23.7 | 20.0 | 7.2–32.8 |
| Hispanic | 14.1 | 12.7–15.6 | 12.5 | 5.2–19.9 | 14.5 | 7.1–21.9 | 8.9 | 0.5–17.4 |
| Non-Hispanic other | 8.3 | 7.3–9.2 | 7.5 | 2.0–13.0 | 5.9 | 2.9–8.9 | 6.9 | −1.7–15.4 |
| Marital status | ||||||||
| Married | 52.3 | 51.0–53.6 | 37.9 | 29.3–46.6 | 18.1 | 12.0–24.3 | 13.4 | 3.7–23.2 |
| Cohabitating | 6.7 | 6.1–7.3 | 16.1 | 9.0–23.3 | 16.9 | 9.0–23.3 | 13.8 | 1.3–26.3 |
| Never married | 18.9 | 17.8–20.1 | 37.6 | 28.6–46.5 | 50.7 | 41.4–60.0 | 48.7 | 32.8–64.6 |
| Previously married | 22.1 | 21.2–22.9 | 8.4 | 21.2–22.9 | 14.3 | 9.4–19.1 | 24.1 | 12.1–36.1 |
| Family income ($1000) | 76.4 | 74.3–78.4 | 74.1 | 60.6–87.5 | 57.0 | 44.3–69.7 | 56.7 | 36.2–77.2 |
| Education | ||||||||
| Less than high school | 10.8 | 10.0–11.7 | 11.5 | 3.0–19.9 | 9.0 | 3.2–14.9 | 19.1 | 6.6–31.6 |
| High school diploma or GED | 22.9 | 21.8–23.0 | 12.0 | 6.8–17.2 | 21.7 | 14.4–29.0 | 8.8 | 3.0–14.6 |
| Some college | 31.6 | 30.5–32.7 | 32.1 | 23.2–40.9 | 40.9 | 31.9–49.9 | 33.9 | 19.1–48.8 |
| Bachelor's degree or higher | 34.7 | 33.2–36.1 | 44.5 | 35.4–53.5 | 28.4 | 20.8–35.9 | 38.1 | 22.4–53.9 |
| Region | ||||||||
| Northeast | 19.5 | 17.7–21.3 | 23.0 | 14.1–31.9 | 20.0 | 12.1–28.0 | 22.2 | 8.8–35.5 |
| Midwest | 21.6 | 20.3–23.0 | 19.2 | 10.3–28.1 | 21.9 | 15.2–28.6 | 18.3 | 7.6–29.0 |
| South | 36.6 | 34.4–38.7 | 34.0 | 24.7–43.3 | 31.9 | 23.4–40.4 | 36.8 | 21.8–51.8 |
| West | 22.3 | 20.4–24.2 | 23.8 | 17.1–30.4 | 26.1 | 17.4–34.8 | 22.8 | 9.0–36.5 |
| Importance for providers to understand/share culture | ||||||||
| Not important at all | 48.4 | 47.0–49.8 | 48.9 | 39.3–58.6 | 50.8 | 42.0–59.6 | 34.5 | 19.4–49,5 |
| Slightly important | 11.9 | 11.1–12.6 | 8.7 | 4.1–13.3 | 18.9 | 10.4–27.4 | 13.8 | 4.4–23.3 |
| Somewhat important | 19.5 | 18.5–20.5 | 22.9 | 15.5–30.3 | 15.2 | 10.1–20.3 | 27.2 | 12.0–42.5 |
| Very important | 20.3 | 19.1–21.4 | 19.5 | 12.0–26.9 | 15.1 | 8.9–21.3 | 24.5 | 11.5–37.4 |
| Frequency of seeing providers who share culturea | ||||||||
| None of the time | 7.6 | 6.7–8.5 | 8.3 | 0.8–15.8 | 13.6 | −0.4–27.7 | 7.1 | −0.4–14.7 |
| Some of the time | 21.0 | 19.7–22.3 | 20.4 | 10.0–30.8 | 26.2 | 14.1–38.4 | 20.7 | 4.6–36.7 |
| Most of the time | 32.5 | 30.9–34.1 | 44.7 | 31.3–58.1 | 35.1 | 22.8–47.5 | 41.5 | 21.8–61.1 |
| Always | 38.9 | 37.2–40.6 | 26.7 | 17.3–36.0 | 24.9 | 15.3–34.7 | 30.7 | 13.2–48.3 |
| Frequency of being treated with respect by providers | ||||||||
| None of the time | 0.6 | 0.4–0.7 | 0.8 | −0.7–2.1 | 0.9 | −0.4–2.2 | 0.0 | 0.0 |
| Some of the time | 2.6 | 2.2–3.0 | 3.9 | 1.1–6.7 | 5.9 | 2.6–9.3 | 6.9 | 0.3–13.4 |
| Most of the time | 15.4 | 14.6–16.2 | 16.2 | 9.6–22.6 | 25.1 | 17.3–32.8 | 30.4 | 16.6–44.3 |
| Always | 81.4 | 80.5–82.3 | 79.2 | 72.4–86.1 | 68.1 | 59.9–76.2 | 62.7 | 48.2–77.3 |
| Frequency of providers asking opinions/beliefs about care | ||||||||
| None of the time | 20.6 | 19.5–21.6 | 25.0 | 16.5–33.6 | 20.3 | 12.7–28.0 | 18.8 | 5.1–32.6 |
| Some of the time | 19.7 | 18.7–20.7 | 20.9 | 12.4–29.4 | 27.4 | 19.6–35.2 | 27.5 | 13.1–41.9 |
| Most of the time | 24.0 | 22.9–25.0 | 25.4 | 17.1–33.7 | 24.8 | 16.3–33.3 | 30.2 | 15.3–45.1 |
| Always | 35.8 | 34.5–37.0 | 28.7 | 21.3–36.1 | 27.5 | 19.6–35.3 | 23.5 | 11.7–35.2 |
| Frequency of providers giving easy-to-understand information | ||||||||
| None of the time | 1.5 | 1.2–1.8 | 1.1 | −0.5–2.8 | 1.0 | −0.2–2.1 | 1.3 | −1.2–3.8 |
| Some of the time | 6.1 | 5.5–6.7 | 4.3 | 1.2–7.3 | 4.4 | 1.8–7.0 | 2.9 | −0.1–6.5 |
| Most of the time | 25.1 | 24.0–26.1 | 24.5 | 16.8–32.1 | 25.5 | 18.4–32.6 | 30.1 | 17.1–43.1 |
| Always | 67.4 | 66.1–68.6 | 70.1 | 62.0–78.2 | 69.2 | 61.7–76.7 | 65.7 | 52.1–79.4 |
| Satisfaction with care | ||||||||
| Very dissatisfied | 1.4 | 1.1–1.7 | 0.3 | −0.3–0.9 | 2.1 | 0.4–3.8 | 0.0 | 0.0 |
| Somewhat dissatisfied | 3.1 | 2.7–3.5 | 6.2 | 2.0–10.4 | 9.2 | 4.3–14.0 | 8.9 | 1.8–16.0 |
| Somewhat satisfied | 23.6 | 22.5–24.7 | 28.2 | 19.5–36.9 | 29.5 | 21.5–37.5 | 35.9 | 20.4–51.3 |
| Very satisfied | 71.9 | 70.7–73.1 | 65.3 | 56.1–74.5 | 59.2 | 50.5–67.9 | 55.3 | 39.6–70.9 |
The question was only asked of respondents who expressed that it is slightly, somewhat, or very important for health care providers to understand/share their culture, and thus the estimates are based on a subset of the sample (n = 6098).
Table 3 summarizes the associations between sexual identity and health care experiences for men and women, respectively, adjusted for variation in sociodemographic characteristics. Overall, the results suggest that sexual minority men did not perceive their health care providers as less culturally competent than did heterosexual men. Compared with heterosexual men, gay men had significantly higher odds of considering it important that providers understand or share their culture (AOR = 1.4; p < 0.05). They also had higher odds of reporting that providers ask for their opinions or beliefs about their medical care, including the types of tests, procedures, or medications they prefer (AOR = 1.5; p < 0.01). No significant differences between sexual minority and heterosexual men were found in other variables of health care experience. Analyses that combined all sexual minority groups exhibited similar findings.
Table 3.
Adjusted Associations Between Sexual Identity and Health Care Experiences by Gender, National Health Interview Survey 2017
| Men (n = 9188) |
Women (n = 12,432) |
|||
|---|---|---|---|---|
| AORa | 95% CI | AOR | 95% CI | |
| Importance for providers to understand/share culture | ||||
| Heterosexual (reference) | 1.0 | 1.0 | 1.0 | 1.0 |
| Gay/lesbian | 1.4* | 1.0–2.0 | 1.0 | 0.7–1.6 |
| Bisexual | 0.9 | 0.4–1.8 | 0.8 | 0.6–1.1 |
| Something else | 1.7 | 0.7–3.8 | 1.7 | 1.0–3.0 |
| All sexual minority men or women combined (L/G, B, and SE) | 1.3 | 0.9–1.8 | 1.0 | 0.8–1.2 |
| Frequency of seeing providers who share cultureb | ||||
| Heterosexual (reference) | 1.0 | 1.0 | 1.0 | 1.0 |
| Gay/lesbian | 1.4 | 0.9–2.2 | 0.7 | 0.5–1.0 |
| Bisexual | 1.6 | 0.7–3.4 | 0.6 | 0.4–1.0 |
| Something else | 0.6 | 0.2–1.7 | 0.8 | 0.5–1.5 |
| All sexual minority men or women combined | 1.3 | 0.9–1.8 | 0.7* | 0.5–0.9 |
| Frequency of being treated with respect by providers | ||||
| Heterosexual (reference) | 1.0 | 1.0 | 1.0 | 1.0 |
| Gay/lesbian | 1.4 | 0.9–2.1 | 0.9 | 0.6–1.4 |
| Bisexual | 0.9 | 0.4–1.8 | 0.6** | 0.4–0.8 |
| Something else | 0.4 | 0.2–1.2 | 0.4** | 0.2–0.8 |
| All sexual minority men or women combined | 1.1 | 0.7–1.5 | 0.7** | 0.5–0.8 |
| Frequency of providers asking opinions/beliefs about care | ||||
| Heterosexual (reference) | 1.0 | 1.0 | 1.0 | 1.0 |
| Gay/lesbian | 1.5** | 1.2–2.0 | 0.8 | 0.6–1.1 |
| Bisexual | 0.9 | 0.5–1.6 | 0.8 | 0.6–1.1 |
| Something else | 1.1 | 0.7–1.6 | 0.8 | 0.5–1.3 |
| All sexual minority men or women combined | 1.3* | 1.0–1.6 | 0.8* | 0.7–0.9 |
| Frequency of providers giving easy-to-understand information | ||||
| Heterosexual (reference) | 1.0 | 1.0 | 1.0 | 1.0 |
| Gay/lesbian | 1.2 | 0.8–1.7 | 1.2 | 0.8–1.7 |
| Bisexual | 1.5 | 0.8–2.6 | 1.1 | 0.8–1.6 |
| Something else | 0.5 | 0.2–1.0 | 1.0 | 0.6–1.8 |
| All sexual minority men or women combined | 1.1 | 0.8–1.5 | 1.1 | 0.9–1.5 |
| Satisfaction with care | ||||
| Heterosexual (reference) | 1.0 | 1.0 | 1.0 | 1.0 |
| Gay/lesbian | 1.2 | 0.8–1.8 | 0.8 | 0.5–1.1 |
| Bisexual | 1.0 | 0.5–1.8 | 0.6* | 0.4–0.9 |
| Something else | 0.7 | 0.3–1.5 | 0.5* | 0.3–1.0 |
| All sexual minority men or women combined | 1.1 | 0.8–1.5 | 0.7** | 0.5–0.9 |
Odds ratio adjusted for all sociodemographic variables.
Estimates are based on a subset of the sample (n = 3901 for men and n = 6098 for women).
p < 0.05.
p < 0.01.
AOR, adjusted odds ratio; B, bisexual; L/G, lesbian/gay; SE, something else.
The results for health care experiences among women highlight a different pattern from those of men. Overall, women who identified as bisexual or something else had poorer health care experiences than heterosexual women. In particular, compared with heterosexual women, both bisexual- (AOR = 0.6; p < 0.01) and something else-identified women (AOR = 0.4; p < 0.01) had lower odds of reporting being treated with respect by providers. They also reported lower satisfaction with care received (bisexual: AOR = 0.6, p < 0.05; something else: AOR = 0.5, p < 0.05). In addition, when all sexual minority women were combined, the odds of seeing providers who share culture and having providers who ask their opinions/beliefs about care were also significantly lower among sexual minority women than among heterosexual women.
There is some evidence supporting differences between sexual minority groups. Among men, those identified as something else had lower odds of reporting being treated with respect by providers and of providers giving easy-to-understand information than gay men (p's < 0.05). Similarly, something else-identified women had lower odds of reporting being treated with respect by providers than lesbian women (p < 0.05). Detailed test results are available on request.
Table 4 shows the interaction effects of sexual minority status and gender on health care experiences and confirms that sexual minority women faced more health care disadvantages than sexual minority men in four aspects, including reports of seeing providers who share culture (p < 0.01), being treated with respect (p < 0.05), providers asking opinions/beliefs about care (p < 0.01), and satisfaction with care (p < 0.05). These results suggest that sexual minority women had poorer experiences compared not only with heterosexual women (as Table 3 demonstrates), but also with sexual minority men. Interactions between individual sexual identities and gender showed consistent findings, particularly for lesbian and bisexual women (Supplementary Table S2); however, most interactions did not reach statistical significance, likely because of small sample sizes.
Table 4.
Main and Interaction Effects of Sexual Minority Status (Lesbian/Gay, Bisexual, and Something Else) and Gender on Health Care Experiences, National Health Interview Survey 2017 (n = 12,432)
| AORa | 95% CI | |
|---|---|---|
| Importance for providers to understand/share culture | ||
| Sexual minority status (reference: heterosexual) | 1.3 | 1.0–1.7 |
| Women (reference: men) | 1.3*** | 1.2–1.4 |
| Sexual minority status × Women | 0.8 | 0.5–1.1 |
| Frequency of seeing providers who share cultureb | ||
| Sexual minority status | 1.3 | 0.9–1.7 |
| Women | 1.1 | 1.0–1.2 |
| Sexual minority status × Women | 0.6** | 0.4–0.8 |
| Frequency of being treated with respect by providers | ||
| Sexual minority status | 1.1 | 0.7–1.5 |
| Women | 1.0 | 0.9–1.1 |
| Sexual minority status × Women | 0.6* | 0.4–1.0 |
| Frequency of providers asking opinions/beliefs about care | ||
| Sexual minority status | 1.3* | 1.0–1.6 |
| Women | 1.1* | 1.0–1.1 |
| Sexual minority status × Women | 0.6** | 0.5–0.9 |
| Frequency of providers giving easy-to-understand information | ||
| Sexual minority status | 1.1 | 0.8–1.5 |
| Women | 1.0 | 1.0–1.1 |
| Sexual minority status × Women | 1.0 | 0.7–1.5 |
| Satisfaction with care | ||
| Sexual minority status | 1.1 | 0.8–1.5 |
| Women | 1.0 | 0.9–1.1 |
| Sexual minority status × Women | 0.6* | 0.4–0.9 |
Odds ratio adjusted for all sociodemographic variables.
Estimates are based on a subset of the sample (n = 9999).
p < 0.05.
p < 0.01.
p < 0.001.
Discussion
Sexual minority individuals have poorer access to and utilization of health care services than their heterosexual counterparts.1,2 Prior research, primarily based on qualitative data, has indicated that sexual minority individuals' barriers to health care are attributable to the lack of training in sexual minority health care and low cultural competency and prejudice among health providers.8,9,14 However, little is known about how prevalent it is for sexual minority individuals to experience less culturally competent care compared with their heterosexual counterparts at the population level. In addition, few studies have examined whether inequality in one's health care experience depends on gender. The current study used nationally representative data to address these underexplored questions.
Our findings highlight that among people who had used health services in the past year, sexual minority men were no more disadvantaged in receiving culturally competent or satisfying care than heterosexual men. Contrary to our expectation, gay men reported some more positive experiences in clinical encounters, including being more frequently asked by providers for their opinions/beliefs about medical care. In contrast, sexual minority women had more negative health care experiences than heterosexual women. In particular, bisexual- and something else-identified women reported being treated with less respect by providers and less satisfaction with care. Sexual minority women overall also less often reported seeing providers who share culture or being consulted by providers about their opinions/beliefs about care compared with heterosexual women. The differential experiences between sexual minority men and women were confirmed by analysis of the interaction between sexual orientation and gender.
Our findings have several implications. First, although gay men may face more prejudice and discrimination in the health care system than their heterosexual counterparts,13,15 they may report having better communication with providers for a few potential reasons. Grassroots activism and community mobilization for gay men living with HIV/AIDS since the 1980s has contributed to health information sharing and enhanced health care services for the gay community,21,22 which may have increased both awareness of seeking culturally competent care and access to such care. However, bisexual and other sexual minority men may benefit less from such community-based efforts due to their marginalized positions in sexual minority communities.23 Moreover, prior studies have argued that hegemonic masculinity hinders health-promoting behaviors, including preventive care utilization and timely care seeking,24,25 suggesting that heterosexual men may have less or poorer communication with providers than sexual minority men.
Second, lower respect and lower satisfaction perceived by bisexual- and something else-identified women in comparison to heterosexual women suggest more stigma and less adequate care experienced by these groups. Our findings are consistent with research showing health disadvantages among bisexual relative to heterosexual and lesbian/gay people26,27 and studies noting that bisexual women are less likely to disclose their sexual orientation to health providers than lesbian women.28,29 The findings also reflect that providers' lack of sexuality knowledge or willingness to listen to patients' needs10,12 may impact bisexual and something else-identified women the most. Accordingly, medical education needs to provide more training on diverse sexuality/gender and related cultural values, beliefs, and customs.14
Lastly, to our surprise, a large share of the respondents (35%–58%, depending on sexual orientation and gender) reported that it is not important at all for providers to understand or share their culture. This finding implies that many Americans still expect health care encounters to be culturally neutral and that policies need to increase the public's awareness of the value of culturally sensitive care.
Limitations
Our analysis focused only on those who were seen by a health care provider in the past 12 months as the NHIS supplementary questions about the cultural competency of providers were only asked of this subsample. Therefore, we do not know the preferences for and experiences of culturally competent care among those who were not seen recently by a health care provider. Although it is likely that these individuals are generally healthier and do not need health care, some of them may have avoided seeking health services for fear of stigmatization or mistreatment by health providers because of their sexual orientation. As Supplementary Table S1 shows, the percentage of having seen a provider in the past year (i.e., % eligible cases) varied by sexual orientation and is consistent with findings about experiences with culturally competent care: Gay men were more likely to see a provider than heterosexual men, whereas women of any minority identity tended to see a provider less often than heterosexual women. Accordingly, our results may present conservative estimates for the frequency of negative health care experiences among sexual minority groups. To better understand the need for and provision of culturally competent care in U.S. society, future survey research should measure whether concerns about providers' cultural competency are reasons for delaying or skipping needed health care.
Further, although this study is based on a nationally representative sample, the sample sizes for some sexual minority groups (e.g., men who identified as bisexual or something else) were small. Some differences across groups may not have been detected because of the limited power of analysis. Case-wise deletion of those missing information on covariates (∼5% of the eligible sample), including sexual orientation, may also slightly bias our results. In addition, the definition of “culture” used in two of the outcome variables did not specify sexual orientation as a cultural aspect. This may influence the reports of preference for and use of providers who understand/share culture. Finally, the categorization of gender in our study is binary due to a conventional survey design. An increasing number of studies have shown that transgender and nonbinary individuals are highly likely to be denied health services and to encounter incompetent health providers.30,31 Survey measures of gender in national health studies should reflect the gender diversity of the population so that scholars, practitioners, and policymakers can acknowledge and address the health care concerns of noncisgender people.
Conclusion
Our study makes significant contributions to the understanding of disparities in culturally competent care by sexual orientation at the national level. Complementing prior research based on qualitative methods, our findings provide insight on an uneven distribution of adequate health care resources across sexual orientation and gender groups. We especially highlight the need to address unique barriers to care among women of bisexual and something else identities and, in some circumstances, men of something else and heterosexual identities. More training on providers' knowledge and sensitivity about diverse sexuality and gender will improve the quality of health care encounters for patients with different needs.
Supplementary Material
Acknowledgments
The authors thank the Diversity Research Network of Michigan State University for supporting this research.
Authors' Contributions
The lead author developed the research questions, conducted the analyses, and drafted the article. The co-author conducted the literature review and drafted and edited the article. Both authors reviewed and approved of the article before submission.
Disclaimer
The content is solely the responsibility of the authors. The National Health Interview Survey and the National Institute on Aging played no role in the study design; collection, analysis, and interpretation of the data; writing the article; or the decision to submit the article for publication.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The study was partially funded by the National Institute on Aging (R01AG061118).
Supplementary Material
References
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