Blog & News
SHADAC at the 2023 AcademyHealth Annual Research Meeting
June 1, 2023:A number of SHADAC researchers will be presenting their work at the 2023 AcademyHealth Annual Research Meeting (ARM) taking place in Seattle, WA from Saturday, June 24 to Tuesday, June 27. For details on research topics and where you can find their posters and presentations, see below.
Association of Discrimination Based on Sexual Orientation and Gender Identity with Health Care Access and Health Outcomes
Presented in “Building the Evidence on Under-Recognized Populations” session on Monday, June 26, 2023 at 1:00 PM.
Discrimination based on sexual orientation and gender identity (SOGI) represents an important barrier to health care access. Few studies have examined SOGI-based discrimination experienced in a health care setting and its association with health care access and health outcomes, including confidence in getting care and physical and mental health. Our study fills this gap by using inclusive SOGI data and correlating direct reports of discrimination with a range of health-related outcomes. Download the presentation slides here.
Authors: Natalie Schwehr Mac Arthur (Presenter), Kathleen Panas, Kathleen T. Call
Supporting Families: Associations between Neighborhood Support and Child Health Outcomes
Presented in “Child and Family Health Poster Session” on Monday, June 26th from 2:45 PM-4:00 PM.
Living in a supportive neighborhood is one measure of social capital, which is an important social determinant of health. However, few nationally representative studies have examined the relationship between neighborhood support and the health status of children, including adverse childhood experiences (ACEs). We fill this gap using nationally representative data that includes important information on neighborhood and family characteristics.
Authors: Natalie Schwehr Mac Arthur (Presenter), Colin Planalp, Lynn A. Blewett
Factors Associated with COVID-19 Symptoms Longer Than Three Months (long COVID): Evidence from the Household Pulse Survey
Presented in “Best Student Poster Symposium” from 11:00 AM-12:30 PM and “Poster Session A” from 3:30 PM-4:45 PM, on Sunday, June 25th.
Prior research on long COVID focuses on biological determinants; however, recent commentary suggests incorporating social and experiential factors into models of the disease may provide more explanatory power. We use the Household Pulse Survey–a survey administered collaboratively through multiple federal agencies–to help answer this question.
Authors: James Campbell (Presenter), Lynn A. Blewett, Robert Hest
Blog & News
Examining Discrimination and Health Care Access by Sexual Orientation in Minnesota
March 22, 2023:Authors: Natalie Mac Arthur, Jeremy Duval, Kathleen Call
More than one-third of lesbian/gay adults in Minnesota reported experiencing discrimination from health care providers based on their sexual orientation and gender identity. |
Survey Question OverviewIn this analysis, we examined the experiences of adults in Minnesota by sexual orientation using data from the biennial 2021 Minnesota Health Access Survey (MNHA). The MNHA asked respondents how often their gender, sexual orientation, gender identity, or gender expression cause health care providers to treat them unfairly. In addition to this measure of SOGI-based discrimination, this survey includes information on access to health care such as forgone care due to costs. |
Introduction
Discrimination based on sexual orientation and gender identity (SOGI) from health care providers is a barrier to creating an equitable health care system. Nearly one in five lesbian, gay, bisexual, transgender, and queer (LBGTQ) adults reports avoiding health care due to anticipated discrimination (Casey et al., 2019). Compared with straight adults, lesbian/gay and bisexual adults are more likely to forgo or delay health care (Jackson et al., 2016, Nguyen et al., 2018). However, less is known about the association between reports of SOGI-based discrimination from health care providers and health care access.
We included three sexual orientation categories in this study: straight, lesbian/gay, and bisexual/pansexual. Survey respondents also had the option to select “none of these” and write in their own response. Due to sample size limitations, we excluded observations with responses that we could not recode to the existing categories. We tabulated SOGI-based discrimination and four measures of health care access by sexual orientation for adults in Minnesota. We also examined differences in health care access for respondents who did and did not report discrimination.
Results
Reports of discrimination from health care providers based on SOGI were significantly higher among lesbian/gay (36.1%) and bisexual/pansexual (26.1%) populations compared with the state average of 6% (Figure 1). Sexual minorities were also more likely to report barriers to health care access when compared with all adults in Minnesota (Figure 2). Low confidence in getting needed health care was significantly above the state average (11.8%) for people who identify as bisexual/pansexual (30.6%). Statewide, over a quarter of adults reported forgone care due to costs (26.2%), which included routine medical care, prescription drugs, dental care, specialists, and mental health care. Rates of forgone care were significantly higher for people who identify as lesbian/gay (45.5%) or bisexual/pansexual (41.9%).
Figure 1. Unfair treatment from health care providers based on gender or sexual orientation in Minnesota
^ Rate significantly different from All Adults at the 95% confidence level.
Source: SHADAC analysis of the 2021 Minnesota Health Access Survey.
Figure 2. Health care access and barriers to care
^ Rate significantly different from All Adults at the 95% confidence level.
† Estimate may be unreliable due to limited data (relative standard error greater than or equal to 30%).
Source: SHADAC analysis of the 2021 Minnesota Health Access Survey.
We found that Minnesotans who experienced SOGI-based discrimination were more likely to have low confidence in getting care and forgone care compared to those who did not experience discrimination (Figure 3). People who experienced discrimination had elevated barriers across all population groups including people identifying as straight, lesbian/gay, or bisexual/pansexual. However, low confidence in care was highest among bisexual/pansexual adults who reported SOGI-based discrimination (39.4%). Half of all adults with SOGI-based discrimination reported forgone care due to costs, while about two-thirds of bisexual/pansexual (69.0%) and lesbian/gay (66.1%) adults who reported SOGI-based discrimination had forgone care.
Figure 3. Experiences of gender-based discrimination associated with barriers to health care access
* Significant difference within a given subpopulation between rates of people who experienced unfair treatment and those who did not.
† Estimate may be unreliable due to limited data (relative standard error greater than or equal to 30%).
Source: SHADAC analysis of the 2021 Minnesota Health Access Survey.
Discussion
MethodsData are from the 2021 Minnesota Health Access (MNHA) survey, which is a biennial population-based survey on health insurance coverage and access conducted in collaboration with the Minnesota Department of Health. We limited the analysis to adults responding for themselves about experiences of discrimination and access (n=10,003); we excluded proxy reports (e.g., a household member answering for a spouse or roommate). Tests for statistical significance were conducted at the 95% confidence level. |
Within the health care setting, discrimination based on SOGI was prevalent among lesbian/gay and bisexual/pansexual adults. SOGI-based discrimination from health care providers was reported by over a third of lesbian/gay adults in Minnesota and over a quarter of bisexual/pansexual adults. Barriers to health care access, including low confidence in getting care and forgone care, were also high among lesbian/gay and bisexual/pansexual adults compared with the average rates seen among adults in Minnesota. Further, reports of SOGI-based discrimination correlated with even higher rates of barriers to access among lesbian/gay and bisexual/pansexual adults; a majority of these populations who reported discrimination also had forgone health care due to costs.
Discrimination by health care providers has substantial clinical implications. Across populations, discrimination negatively affects mental and physical health (Pascoe and Richman, 2009). Compared with straight adults, lesbian/gay and bisexual adults experience health disparities including mental and physical health, activity limitations, and chronic conditions (Gonzales and Henning-Smith, 2017). For LBGTQ adults, both discrimination and barriers to health care are associated with worse mental health, behavioral health, and health-related quality of life (Lee 2016 et al., Jung et al., 2023). One recent study suggests that delayed health care partially mediates the connection between discrimination and worse health status among LBGTQ women (Scott et al., 2022). Our work contributes evidence linking provider discrimination to forgone health care and lack of confidence in getting care.
The clinical impact of discrimination is likely to vary across the life course and across the spectrum of intersectional identities including LBGTQ and race/ethnicity. Compared with lesbians, bisexual women are more likely to report poor physical and mental health and disabilities; both groups of women face higher risks than straight women (Fredriksen-Goldsen 2023). Gay Black and Hispanic men face greater barriers to health care access than gay white men (Hsieh et al., 2017). Among older adults, one survey found that nearly four out of five LBGTQ people anticipate encountering discrimination in long-term care services (Dickson et al., 2022).
Differences in health care access and socioeconomic resources may exacerbate the influence of provider discrimination on health outcomes. Although studies have found that delays in health care among lesbian/gay and bisexual adults persist even with insurance coverage, their coverage may not provide comparable affordability of health care relative to straight adults (Jackson et al., 2016, Nguyen et al., 2018,Tabaac et al., 2020). Lesbian/gay and bisexual adults are less likely to have private coverage and more likely to have purchased a plan from the individual market, which may have higher premiums and deductibles. Furthermore, they are also more likely to experience lapses in coverage. These studies indicate that both cost concerns and previous bad health care experiences contribute to delays in care. Our results add to the growing body of literature documenting high rates of forgone care due to cost for lesbian/gay and bisexual/pansexual adults. Additionally, we document lack of confidence in getting health care among these populations and greater barriers to access among those who reported SOGI-based discrimination from a health care provider.
Conclusion
Reports of discrimination among lesbian/gay and bisexual/pansexual Minnesotans are troubling and require a response. The Affordable Care Act, which expanded Medicaid in willing states, also expanded non-discrimination protections based on sexual orientation and gender identity (KFF, 2014). However, these protections are limited in promoting health care access. Relative to other states, Minnesota offers a robust Medicaid program. Barriers to access may be even higher for LBGTQ people in states that did not expand Medicaid and states with fewer protective non-discrimination laws. Socioeconomic policies at the federal and state level are important for addressing gaps in health equity for many members of the LBGTQ community.
Greater availability of data including SOGI measures would strengthen efforts to better understand and address the health care needs of LBGTQ populations (SHADAC, 2021). Direct measures of discrimination are also important to monitor progress in providing equitable access to health care services (Lett et al., 2022). Ongoing research is needed to improve health equity and address barriers to health care for LBGTQ populations.
Check out our companion blog "Examining Gender-Based Discrimination in Health Care Access by Gender Identity in Minnesota".
References
Casey, L. S., Reisner, S. L., Findling, M. G., Blendon, R. J., Benson, J. M., Sayde, J. M., & Miller, C. (2019). Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health services research, 54 Suppl 2(Suppl 2), 1454–1466. https://doi.org/10.1111/1475-6773.13229
Dickson, L., Bunting, S., Nanna, A., Taylor, M., Spencer, M., & Hein, L. (2022). Older Lesbian, Gay, Bisexual, Transgender, and Queer Adults’ experiences with discrimination and impacts on expectations for long-term care: Results of a survey in the southern United States. Journal of Applied Gerontology, 41(3), 650-660.
Fredriksen-Goldsen, K. I., Romanelli, M., Jung, H. H., & Kim, H. J. (2022). Health, economic, and social disparities among Lesbian, Gay, Bisexual, and Sexually Diverse Adults: Results from a population-based study. Behavioral Medicine, 1-12.
Gonzales, G., & Henning-Smith, C. (2017). Health disparities by sexual orientation: results and implications from the Behavioral Risk Factor Surveillance System. Journal of Community Health, 42, 1163-1172.
Jackson, C. L., Agénor, M., Johnson, D. A., Austin, S. B., & Kawachi, I. (2016). Sexual orientation identity disparities in health behaviors, outcomes, and services use among men and women in the United States: A cross-sectional study. BMC Public Health, 16(1), 807. https://doi.org/10.1186/s12889-016-3467-1
Kates, J., & Ranji, U. (2014, February 21). Health Care Access and Coverage for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community in the United States: Opportunities and Challenges in a New Era. KFF. https://www.kff.org/racial-equity-and-health-policy/perspective/health-care-access-and-coverage-for-the-lesbian-gay-bisexual-and-transgender-lgbt-community-in-the-united-states-opportunities-and-challenges-in-a-new-era/
Lett E., Asabor E., Beltrán S., Cannon A.M., Arah O.A. (2022). Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research. Ann Fam Med 20(2):157-163. https://doi.org/10.1370/afm.2792
Nguyen, K. H., Trivedi, A. N., & Shireman, T. I. (2018). Lesbian, gay, and bisexual adults report continued problems affording care despite coverage gains. Health Affairs, 37(8), 1306-1312.
Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: a meta-analytic review. Psychological bulletin, 135(4), 531.
Scott, S. B., Knopp, K., Yang, J. P., Do, Q. A., & Gaska, K. A. (2022). Sexual minority women, health care discrimination, and poor health outcomes: A mediation model through delayed care. LGBT Health. http://doi.org/10.1089/lgbt.2021.0414
SHADAC. (2021, October). A New Brief Examines the Collection of Sexual Orientation and Gender Identity (SOGI) Data at the Federal Level and in Medicaid. https://www.shadac.org/news/new-brief-examines-collection-sexual-orientation-and-gender-identity-sogi-data-federal-level
Tabaac, A. R., Solazzo, A. L., Gordon, A. R., Austin, S. B., Guss, C., & Charlton, B. M. (2020). Sexual orientation-related disparities in health care access in three cohorts of US adults. Preventive Medicine, 132, 105999.
Blog & News
To Improve Health Equity, Treat Disparities in Adverse Childhood Experiences
February 15, 2023:Twenty-five years ago, a watershed study on adverse childhood experiences (ACEs) first established a relationship between childhood trauma and long-term health impacts that can last well into adulthood.1 Since then, numerous related studies have corroborated the association between ACEs and mental health and substance use disorders as well as diseases such as cancer, diabetes, and heart disease.2
Today, many public health experts recognize childhood trauma as a public health threat, not so different from the threat posed by infectious diseases such as COVID-19. And, similar to the way that medical science has developed tools such as vaccines to prevent illness caused by pathogens, research has identified strategies that can prevent childhood trauma or provide children and families with tools to limit more lasting harms.3
As with other public health strategies, identifying populations most at risk for harm can help focus interventions to improve people’s health and lives. To do that for ACEs, it is critical to understand disparities in children’s exposure to traumatic experiences.
Disparities in ACEs exposure
In a recent SHADAC study, researchers used data from the federally sponsored National Survey of Children’s Health, which includes questions on several experiences generally considered to be ACEs, such as children’s separation from parents due to death, incarceration, or divorce; exposure to violence in the home or neighborhood; and difficulty affording basic necessities, such as food and housing. Because our aim was to produce estimates of ACEs exposure for different demographic groups, we combined multiple years of the survey (2016-2019) to enhance our ability to produce reliable estimates.
The findings of our analysis were deeply troubling. Nationally, almost half of U.S. children had exposure to at least one ACE, and more than half of children had an ACE exposure in 13 states. There was no state where ACEs were rare; even in Minnesota, the state with the lowest rate, more than one-third of children had exposure to at least one ACE.
Disparities in exposure to potentially traumatic childhood experiences were even larger across demographic groups than across the states. By race and ethnicity, Black children and American Indian and Alaska Native children had the highest rates of ACEs exposure, at 63.7 percent and 63.0 percent, respectively. Meanwhile, Asian children and White children had the lowest rates of ACEs exposure, at 25.0 percent and 40.9 percent, respectively. There were similarly large disparities by family income. Children from households with the lowest incomes (200 percent of Federal Poverty Guideline [FPG] or less) had an ACEs exposure rate of 61.9 percent, while those from families with the highest incomes (400 percent of FPG or higher) had a much lower rate of 26.4 percent. Our analysis also found differences by children’s health insurance coverage status and type, as well as by age groups.
ACEs as a health equity issue
Our study showed clear patterns of disparities in exposure to experiences that can create childhood trauma across a multitude of demographic groups—a finding that, in combination with research demonstrating a link between ACEs and long-term health, suggests that working to reduce the prevalence of ACEs and the harm that they cause could pay dividends in improving health equity.
Fortunately, there is a growing body of research that points to strategies for addressing ACEs. For instance, the U.S. Centers for Disease Control and Prevention (CDC) suggests strengthening economic supports for families and promoting family-friendly work policies; ensuring access to high quality childcare and early childhood education; and giving parents and children a toolbox of healthy skills for coping with short-term stress using social-emotional learning and other evidence-based approaches.4
Improving people’s health and lives by addressing the pernicious harm of ACEs will necessarily entail a broader “culture of health” strategy that extends beyond the traditional health care system. But attempting such new approaches may be necessary to break longstanding health equity logjams and provide all children a fair chance at growing into healthy and productive adults.
Download new SHADAC brief "The Kids Aren't Alright: Adverse Childhood Experiences and Implications for Health Equity."
1 Felitti, V.J. et al. (May 1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), P245-258. https://doi.org/10.1016/S0749-3797(98)00017-8
2 Centers for Disease Control and Prevention Vital Signs (2019). Adverse Childhood Experiences (ACEs) Preventing early trauma to improve adult health. https://www.cdc.gov/vitalsigns/aces/pdf/vs-1105-aces-H.pdf
3 Centers for Disease Control and Prevention (2019). Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf
4 Centers for Disease Control and Prevention (2019). Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf
Publication
The Kids Aren't Alright: Adverse Childhood Experiences and Implications for Health Equity
Authors: Colin Planalp, MPA and Andrea Stewart, MA
Drawing on data from the National Survey of Children’s Health, this brief investigates the prevalence of adverse childhood experiences (ACEs) and disparities in ACEs exposure by children’s race, family income, age and health insurance coverage. The disproportionate impact of ACEs has deep ramifications on health equity due to related research showing that ACEs exposure is associated with increased risk for numerous short- and long-term health impacts, varying from mental health and substance use disorders to heart disease and cancer.
To learn more about disparities in ACEs:
- Download State-level data tables of ACEs prevalence by race and ethnicity, family income, age, and health insurance coverage status;
- Check out the accompanying SHADAC blog "To Improve Health Equity, Treat Disparities in Adverse Childhood Experiences"; or
- Visit the Adverse Childhood Experiences measure on State Health Compare.