Health, Mental Health, and Barriers to Care for the LGBTQ Population

LGBTQ Community Health

The health and mental health of lesbian, gay, transgender, and queer/questioning (LGBTQ) populations is affected by multiple factors, many of which being unique to this population. The number of LGBTQ persons in America is found to be between 2-3% of the total population (Romanelli & Hudson, 2017); however, this population remains underserved or ill served by the healthcare industry (Romanelli & Hudson, 2017). The causes for these health disparities are numerous and ever changing as research delves deeper into specific health concerns and causality.

Access to physical and mental health requires opportunities to seek out and reach needed services and to be offered appropriate care when provided (Romanelli & Hudson, 2017). LGBTQ persons already accessing primary or mental health services come upon specific and unique barriers to quality care compared to the care received by the heterosexual cisgender population even though they are more likely to seek treatment (Williams & Fish, 2020). These include both individual and system-level barriers, both having effects on LGBTQ health outcomes.

Mental Health Among LGBTQ Populations

Metal health among LGBTQ populations often go hand-in-hand with physical health and health outcomes; therefore, an overview of mental health issues is in order. The LGBTQ population is riddled with unique societal and personal stressors that contribute to their overall mental health. Some of the most prevalent stressors include social stigma, prejudice, discrimination, victimization, homophobia, internalized homophobia, family dynamics, and denial of civil rights (Fulginiti et al., 2021; Whaibeh, 2019; Yolaç &Meriç, 2020).

These influences often cause members of the LGBTQ community to develop mental health problems at a high rate. The most common mental health conditions seen among the population include depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorders, job discrimination, and alcohol use as well as feelings of helplessness (Macbeth et al., 2021; Whaibeh, 2019; Yolaç &Meriç, 2020). Each of these mental health conditions are represented among the LGBTQ population at higher rates than their heterosexual cisgender peers. These mental health conditions also often correlate with general poor health outcomes.

Physical Health Among LGBTQ Populations

Physical health among the LGBTQ populations can be divided among genders or represented as a whole; however, due to the diversity of the population certain numbers may be an under- or overestimation of physical conditions. Physical conditions range from early predictors of future disease to acquired fatal diseases.

First, members of the LGBTQ community are less likely to have a primary care provider (PCP) (Cigna, 2022). Not having a reliable provider to create a report with can lead to a host of problems when accessing primary care. Even when a PCP has been established LGBTQ persons have reported dissatisfaction with treatment autonomy, equity, and overall clinical outcomes (Whaibeh et al. 2019). Members of the LGBT community have higher rates of HPV infections and are at a higher risk for alcohol, substance, and tobacco use (Cigna, 2022; Shaver et al., 2019).

Women identifying as lesbian or bisexual have higher rates of elevated weight and a decreased likelihood of attending regular yearly pap smears (Shaver et al., 2019). Women identifying as lesbian or bisexual also have higher rates of breast cancer than thier heterosexual, cisgender peers (Cigna, 2022). Regular avoidance of annual checkups puts women identifying as lesbian or bisexual at greater risk of developing undiagnosed diseases and/or diseases caught at later stages of development.

Men who identify as gay or bisexual have higher markers for cardiovascular stress and higher rates of eating disorders proportionally (Shaver et al., 2019). Transgender men also have a higher rate of depression than heterosexual cisgender men or other subcategories within the LGBTQ community (Shaver et al., 2019).

Violence Among LGBTQ Populations

Violence among LGBTQ population members is higher than that of the general population and includes physical and sexual assault, verbal assault, interpersonal trauma, harassment, and bullying (Kassing et al., 2021). Violence at any age can have repercussions on one’s mental and physical health even if the violence happened years in the past. The number of violent cases is highest in rural areas and other areas without specific legislation for LGBTQ protection (Backhaus et al., 2019).

Sexual assault rates are reported as high as 10% within the LGBTQ community with an average of 2% of those identifying as heterosexual (Kassing et al., 2021) and an average of 30% reporting being threatened or physically attacked (Kassing et al., 2021). These types of discriminatory actions are associated with poor mental and physical health outcomes as well as side effects such as decreased energy levels, concentration difficulties, and lower levels of job retention and earning potential (Backhaus et al., 2019).

There are some methods shown to buffer the effects of violence among LGBTQ college students. Those who felt a sense of belonging, group cohesiveness, and community connectedness showed fewer long-term effects from discriminatory violence than those who felt isolated or excluded (Backhaus et al., 2019). This may also be true for those who feel a sense of belonging or community connectedness in other age ranges.

Suicidality in LGBT Populations

Suicidal ideation and attempts are very high in the LGBTQ population compared to heterosexual cisgender peers. Suicide is already the second leading cause of death among youth aged 10-24 (Fulginti et al., 2021), so increased ideation and attempts among this population make them especially vulnerable. Stigma, prejudice, discrimination, and victimization are reported as the leading factors related to LGBTQ suicidality (Fulginti et al., 2021).

In the general population it is estimated that 12% of adolescents contemplate suicide (Russon et al., 2021). It is reported that suicidality among LGBTQ youth are around 1.6-2.63 times that of the general population (Backhaus et al., 2019). The attributed factors for this include parent-adolescent relationship, family rejection of sexuality, negative familial events, and extrafamilial victimization (Russon et al., 2021). The largest disparity between suicidality in the general population and the LGBTQ population is that of actual suicide attempts (Fulginti et al., 2021).

Transgender male adolescents reported the highest rate of suicidality followed by transgender female adolescents (Fulginti et al., 2021). The rate of suicidal ideation and attempts by members of the LGBTQ population is alarming and warrants research for interventions specific to this population.

LGBTQ Health and Family Dynamics

Family dynamics can play a large role in either exacerbating or buffering symptoms associated with mental health disparities for the LGBTQ community. Some of the largest factors attributed to family dynamics and their effect on the LGBTQ community include rejection of one’s sexuality, inclusivity, acceptance, and religiosity.

Religiosity is often seen as a protective factor that buffers the effects of everyday life for the general population, but this is not always the case for members of the LGBTQ community (Macbeth et al., 2021). Religiosity may be one of the main variables attributed to familial acceptance or exclusion of family members based on sexual orientation. Therefore, it is reasonable to look at it as a marker of future mental health outcomes for LGBTQ members.

Religiosity is seen as the degree to which an individual, or family, hold religious beliefs (Macbeth et al., 2021). Traditionally religiosity has led to members of the LGBTQ community felling excluded and unwelcome as homosexuality has historically been prohibited (Dyer, J.,2021). A family’s religiosity, therefore, can indicate problems among family members’ acceptance of non-heterosexual orientations. Rejection by family members has been associated with increased suicide attempts and higher rates of anxiety and depression (Macbeth et al., 2021).

Barriers to Accessing Quality Care

The barriers to accessing quality care are numerous among the LGBTQ community and are attributed to both individual and systematic barriers. The main barriers include discrimination, poor treatment, insensitivity, geographical availability, appropriateness of service, and competence among providers (Romanelli & Hudson, 2017). Other barriers include lack of self-advocacy, embarrassment, and false expectations by the individual care-seeker (Romanelli & Hudson, 2017).

Often, LGBTQ members believe providers hold negative predispositions toward them, lack competency in their unique care, and are overall less satisfied with treatment (Williams & Fish, 2020). Although some of these may be misconceptions by the care-seeker the reality is that it is enough for them to either delay care or forfeit care altogether. A universal system for teaching LGBTQ care is needed in medical programs.

Some recent suggestions to increase care quality among providers is the idea of culturally responsive care as well as care via telemedicine. Currently 1 in 6 adults is lives with a mental illness, and this number is higher for the LGBTQ population (Waihbeh et al., 2019). Telehealth seems to be a major advantage in meeting the needs of mental and physical care for all populations across geographical and socioeconomic status (Waibeh et al., 2019). Although promising, more needs to be done to meet the unique needs of the LGBTQ population.

Conclusion

The LGBTQ population makes up a large community who have trouble accessing quality physical and mental health services. Much of the problem regarding access has to do with societal discrimination and/or perceptions of such. Little research has been done to identify specific, effective interventions within the LGBTQ populations for both mental and physical health even though these members of the community are at a much higher risk for certain mental and physical health conditions.

Universal teaching practices as well as on-site training specific of the population in the geographic area is warranted and necessary. To provide the best available care for the LGBTQ community, members of the community and providers should tailor care to meet the needs of this population and self-advocacy skills should be taught regarding one’s own health. A multi-faceted approach should be taken to ensure the health and wellbeing of the LGBTQ population. Research should continue to delve into appropriate care interventions for both mental and physical health of the LGBTQ population as well as how to reduce stress factors and societal barriers to appropriate care.

References:

Backhaus, I., Lipson, S., Fisher, L., Kawachi, I., & Padrelli, P. (2021). Sexual assault, sense of belonging, depression and suicidality among LGBQ and heterosexual college students. Journal of American College Health, 69(4), 404-412. https://doi.org/10.1080/07448481.2019.1679155

Cinga. (2022). LQBTQ+ health disparities. Retrieved from https://www.cigna.com/knowledge-center/lgbtdisparities#:~:text=LGBTQ%2B%20people%20are%20less%20likely%20to%20have%20a%20regular%20health%20care%20provider.&text=Lesbian%20and%20bisexual%20women%20have,women%20are%20at%20greater%20risk.&text=LGBTQ%2B%20people%20have%20higher%20rates,related%20cervical%20or%20anal%20cancers.

Dyer, Justin. (2021). Refining research on the intersection between sexual orientation, suicide, and religiosity. American Psychological Association, 24(2), 179-188. https://doi.org/10.1037/rel0000451

Fulginiti, A., Rhoades, H., Mamey, M., Klemmer, C., Srivastana, A., Weskamp, G., & Goldbach, J. (2021). Sexual minority stress, mental health symptoms, and suicidality among LGBTQ youth accessing crisis services. Journal of Youth and Adolescents, 2021(50), 893-905. https://doi.org/10.1007/s10964-020-01354-3

Kassing., F., Casanova, T., Griffin, J., Wood, E., & Stepleman, L. (2021). The effects of polyvictimization on mental and physical health outcomes in an LGBTQ sample. Journal of Traumatic Stress, 2021(34), 161-171. https://doi.org/10.1002/jts.22579

Macbeth, A., Vidales, C., & Vogel, D. (2021). Perceived parental religiosity as a predictor of depression and substance use among LGBTQ+ individuals: The mediating role of perceived familial stigma. American Psychological Association, 14(1), 140-147. https://doi.org/10.1037/rel0000411

Romanelli, M. & Hudson, K. (2017). Individual and systematic barriers to health care: Perspectives of lesbian, gay, bisexual, and transgender adults. American Journal of Orthopsychiatry, 87(6),714-728. https://dx.doi.org/10.1037/ort0000306

Russon, J., Morrissey, J., Dellinger, J., Jin, B., & Diamond, G. (2021). Implementing attachment-based family therapy for depressed and suicidal adolescents and young adults in LGBTQ+ services. Crisis. https://doi.org/10.1027/0227-5910/a000821

Shaver, J., Sharma, A., & Stephenson, R. (2019). Rural primary care providers’ experiences and knowledge regarding LGBTQ health in a midwestern state. The Journal of Rural Health, 2019(35), 362-373. https://doi.org/10.1111/jrh.12322

Whaibeh, E., Mahmoud, H., & Vogt, E. (2019). Reducing the treatment gap for LGBT mental health needs: The potential of telepsychiatry. Journal of Behavioral Health Services and Research, 47(3), 424-431. https://doi.org/10.1007/s11414-019-09677-1

Williams, N. & Fish J. (2020). The availability of LGBT-specific mental health and substance abuse treatment in the united states. Health Services Research, 2020(55), 932-943. https://doi.org/10.1111/1475-6773.13559

Yolaç, E. & Meriç, M. (2020). Internalized homophobia and depression levels in LGBT individuals. Perpectives in Psychiatric Care, 2019(57), 304-310. https://doi.org/10.1111/ppc.12564

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“The totally online DBH program offered by Cummings Graduate Institute of Behavioral Health Studies is focused on the professional I have grown into: a synergistic disrupter for the healthcare industry, who is passionate about Wholistic Healthcare (e.g., health, behavioral health, and Social Determinants of Health and Mental Health), rendered skillfully through interprofessional teams. The program pillars of medical literacy, integrated behavioral health interventions, and entrepreneurship resonate loudly with me. The healthcare industry will continue to change, with doctoral level professionals needed to play a major role in any successful transformation. My goal is to further advance my knowledge-base, professional standing, and industry commitment to be part of these transformational efforts. In this way I can heed the Quadruple Aim: assuring quality-driven patient-centric care is rendered at the right time, through the right population-based treatment processes, at the right cost, and by empowered professionals embracing the work and committed to their charge.”
Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 11, 2020

“In the time that I have been a student at CGI, I have learned that integrated healthcare is no longer the exception; providers want behavioral health clinicians on their team. My courses demonstrate that the services that a DBH can offer are valuable and the opportunities abound. I’m learning that as a DBH, I can work to create a new norm in healthcare, one that promotes holistic care provided by a collaborative team delivering diverse services. I now view behavioral healthcare as a crucial piece of the medical care puzzle, rather than a separate entity. I can see the gaps in care that a DBH can fill and why including a DBH in treatment is critical. I am beginning to see how I will play a role in disrupting healthcare to provide quality treatment while advocating for my patients. Although I may still have to explain my role at times, I am learning that once I do, others will seek out my services. I am gaining confidence in what I bring to the medical team and am continuously expanding my knowledge of what else I can do.”
Jennifer KellyDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - July 26, 2020

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Diane Scott, MSW, LCSWDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - August 7, 2020

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Amy McConnell, LCSWDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - September 18, 2020

“During my tenure as a student at CGI, I wrote a book review that was published in the International Journal of Integrated Care. One of my papers became a newsletter article, a pitch for my population health class became a poster presented at a CFHA conference, a book chapter was developed based on a paper I wrote for my independent study, and I am submitting my CP project to a journal this weekend. So, everything that you write during the program is potentially publishable! You have the advantage of having faculty read and give you feedback on it before submitting it. Take risks! The worst that can happen if you submit a paper for publication is receiving a rejection letter. Well, if you don’t send it you’re already acting as if the paper had been rejected. 😉 Plus, if you receive a rejection letter, it usually comes with feedback, so you can improve your paper and send it again!”
Dr. Liliane de Aguiar-Rocha, DBH, BCBADBH Alumni, Cummings Graduate Institute for Behavioral Health Studies - October 9, 2020

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Pauline Pablo, BCBADBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - November 11, 2020

“My interest in a DBH degree grew out of frustration and hope. On one hand, I grew frustrated with the quality of care my clients with intellectual and developmental disabilities were receiving. As members of a marginalized population who lack the skills to advocate for themselves, the clients I serve receive subpar medical care, mental health care, and behavioral health care. Many healthcare providers are not trained to address the unique language and cognitive challenges present when serving a person with Autism and I/DD.

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Valeria ParejoDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - January 15, 2021

“As a Doctorate of Behavioral Health (DBH) student my vision for healthcare is to disrupt the current model, close gaps to care and create healthcare improvements. In the evolving world of healthcare I believe behavioral healthcare providers (BCP) are essential to the development of integrative healthcare. Once I obtain a DBH degree, I know I will gain a leadership role and be able to add quality to the creation of integration efforts worldwide. I know I will graduate with the essential tools I need to stand at the forefront of integrated healthcare. I want to create healthcare improvements for marginalized populations that are typically underserved or forgotten. As an individual of two minority groups; woman and African American, I am very passionate about helping reduce cultural, ethnic, social economic and geographic disparities within healthcare systems.”
Ebony WatsonDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 30, 2021

“Since beginning my studies at CGI, I have been awakened to how much I truly did not know and understand despite my specialty training in Social Work and behavioral health needs. The classes at CGI allow me to explore topics that I may not have thought to investigate and encourage me to question and think outside the “normal” delivery of behavioral health services. Services that I previously thought were quality and designed to meet the needs of special populations, I now believe to be woefully inadequate to serve the needs of the patients. Patients cannot receive the best quality, efficient, and timely care they need and deserve within institutions that are not integrated. Institutions that continue to silo and do not encourage collaboration and integration are not focused on the needs of the patient.”
Amanda BarnardDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 30, 2021

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Diane ScottDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 29, 2021

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Preventative care can be part of service delivery from a hospital system; we should not rely only on public health programs to tackle social determinants of health. COVID-19 is not only impacting mental health but also how we are delivering medical care. Could COVID-19 be an unintended force for healthcare policy change? Apostolopoulos et al. (2020) reports the complexity presented to the health care system by COVID-19 has created change that will continue in healthcare for years to come. The needed changes to delivery and access will require a policy shift in all levels of healthcare (Apostolopoulos et al., 2020).”
Billie RatliffDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - December 13, 2021

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Arthur Williams IIIDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - July 8, 2022

“As a member of the AAPI community, I’m very familiar with the barriers to mental health services and the need to break through the glass wall of cultural stigma that prevents many from receiving potentially life–saving treatment. I was the only Asian American person in my master’s cohort, the only Asian American person in many of my clinical work settings, the only Asian American person to walk into many of the professional settings that I pushed myself to show up to. In my current practice, I’m constantly reminded by my patients of how difficult it is to find an Asian American mental health provider, though this reminder constantly informs me that more needs to be done for my community. Day after day, I read stories of Asian American people who die by suicide as a consequence of our culture’s avoidance of mental health topics. As a DBH, my biggest goal is to use my expertise in whole–person care to amplify the conversation around mental health and help my community understand that mental healthcare is not a privilege that we are not entitled to, it is a crucial part of our healthcare that will manifest differently in us than what many Western psychology or psychiatry textbooks will describe, and that our unique experience of mental health issues are valid, important, and is time to be part of the larger conversation.”
Willam ChumDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - September 16, 2022

“Pursuing a doctorate in behavioral health is essential in helping to transform my thinking as a healthcare provider; moving from a more traditional mindset, embracing change and a “different world view” of tools for successful client outcomes. This type of advanced study will equip me with the clinical and leadership skills to be a leader on the cutting edge of behavioral health. This type of training would make me an asset to the healthcare workplace; specifically to function effectively as a change agent for the successful outcomes of the workplace and its clients.”
Judith AllenDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - September 23, 2022 Previous Slide