Health equity means that all people have access to care and the opportunity to be as healthy as possible, regardless of their sexual orientation, gender identity, or any other circumstance. Nearly 6% of adults in the United States — or more than 14 million people — identify as lesbian, gay, bisexual, transgender, or nonbinary. Society today is much more accepting, welcoming, and inclusive of all people than it has been in the past. However, some people who identify as LGBTQ+ do experience discrimination in their communities and poor experiences with the health system that can impact their chance to live healthy lives.
One of the biggest obstacles to tackling these inequities is a lack of data — largely due to implicit bias — about social drivers of health and well-being for people who identify as LGBTQ+. Most population-based research surveys have not consistently asked people about their sexual orientation and gender identity, making it more difficult to identify disparities and needed interventions. This gap has prompted the National Institutes of Health (NIH) to identify “sexual and gender minorities” as a “health disparity population” to encourage and support more research.
The U.S. Census Bureau asked Americans about their sexual orientation and gender identity for the first time in 2021, in a national survey examining household experiences during the pandemic. Just over 13% of adults who identify as LGBTQ+ reported living in a household that experienced food insecurity in the past seven days, compared to 7% of heterosexual and cisgender adults.
Sexual Orientation, Gender Identity, and Health
What is known about existing inequities based on sexual orientation and gender identity? In some cases, where people who identify as LGBTQ+ live can affect their safety and well-being. For example, those who live in communities with high levels of prejudice have a life expectancy that is 12 years less than those who reside in more accepting communities.
Nearly one in four people who identify as LGBTQ+ report that they are in fair or poor health, compared to 14% of heterosexual or cisgender adults, according to a Kaiser Family Foundation study. This population can have higher rates of disability or chronic disease and uses tobacco, alcohol, and drugs at higher rates than other populations.
Forty percent of all young people experiencing homelessness identify as LGBTQ+ — and they face increased risk of physical or sexual abuse, STDs, and mental health conditions. Youth who identify as LGBTQ+ are more likely to attempt suicide compared to their peers and to engage in self-harming behaviors.
All of these disparities are exacerbated for transgender people, who can experience high prevalence of HIV/STDs, victimization, mental health conditions, and suicide.
Possible Barriers to Healthcare
While there are many doctors who have been trained and excel in providing care with cultural humility — including the acknowledgment of peoples’ identity and pronouns and familiarity with the terms people use when communicating their needs and concerns — the healthcare system can pose a number of barriers for LGBTQ+ people. Overall, LGBTQ+ people are more likely to report having negative experiences with the healthcare system.
Given these potential experiences, it’s not surprising that some LGBTQ+ people avoid healthcare. Twenty percent of lesbian women and 12% of bisexual women have never seen a doctor or nurse for a gynecological exam, significantly higher than heterosexual and cisgender women (6%).
Transgender people can face challenges finding providers with the expertise to provide proper treatment, such as hormone therapy and surgery. Transgender people also experience other barriers in health systems, including inappropriate electronic records, forms, lab references, and clinic facilities.
Fortunately, the health system is taking steps toward improvement. Each year, the Human Rights Campaign Foundation compiles the Healthcare Equality Index, grading participating healthcare facilities based on how many LGBTQ+ inclusive policies and practices they have in place in four difference criteria, ranging from foundational elements of LGBTQ+ patient-centered care to community engagement. In 2022, 757 facilities earned the status of “LGBTQ+ Healthcare Equality Leader” or “Top Performer.” That was up from 688 in 2020 — even during the COVID-19 pandemic.
Gay, lesbian, bisexual, transgender, and nonbinary people need access to care that is appropriately informed and delivered with cultural humility, as well as physicians who have a strong working knowledge of best practices to help them serve everyone. This requires collaboration on both the national and local levels to advance equity in society and in our communities.
“The healthcare industry has an opportunity to be a leader in equity, and we’re making strides in that direction,” said Dr. Shantanu Agrawal, Elevance Health’s chief health officer. “One clear opportunity is meaningful partnerships with providers in delivering care with cultural humility, gathering data to identify inequities, finding innovation solutions to dismantle barriers to high-quality and timely care, and working to ensure that everyone can be as healthy as possible — regardless of their sexual orientation, gender identity, race, or any other personal attribute.”