Sexual minority adults more likely to avoid care on the basis of patient-clinician identity discordance

By Priyanjana Pramanik, MSc.Reviewed by Danielle Ellis, B.Sc.Sep 18 2024

A new study finds that sexual and gender minority adults are significantly more likely to avoid healthcare due to identity mismatches with clinicians, with discrimination playing a key role.

In a recent study published in The Annals of Family Medicine, researchers investigated the factors contributing to healthcare avoidance among sexual and gender minority (SGM) adults, focusing on patient-clinician identity discordance (PCID).

Their findings indicate that SGM adults are more likely to avoid healthcare services due to identity mismatches with clinicians compared to non-SGM adults, and this avoidance is strongly linked to experiences of healthcare discrimination, emphasizing the need for a more inclusive health system.

Background

Adults from SGM groups tend to have poorer health outcomes compared to non-SGM individuals, partly due to avoiding essential health care services. This is often linked to discrimination and stressors linked to their belonging to minority and marginalized groups.

Previous research has shown that patients whose identities do not match their clinicians' are less likely to receive necessary care and report poorer experiences. While this has been studied in racial identity contexts, little is known about how identity discordance affects SGM patients.

About the study

In this study, researchers aimed to assess how often SGM adults avoid care due to identity mismatches with clinicians and whether healthcare discrimination plays a role in this avoidance.

Researchers used data from the National Institutes of Health's All of Us Research Program, which focuses on recruiting participants from underrepresented communities.

The study included adults in the United States aged 18 and older enrolled between May 2018 and July 2022. It received ethical approval, and all participants gave their consent.

Participants self-identified their sex assigned at birth, gender identity, and sexual orientation to categorize them as gender minority, cisgender,  sexual minority, or heterosexual adults.

Care avoidance due to PCID was measured by asking if participants delayed or skipped care because their clinician belonged to a dissimilar background. Healthcare discrimination was assessed using a validated scale.

The researchers used statistical models to compare care avoidance linked to PCID across gender identity and sexual orientation, adjusting for factors such as age, race, income, education, and health insurance.

They also analyzed how experiences of healthcare discrimination affected care avoidance, using a specialized method to detect trends. Interaction terms were included to see if these associations differed between sexual and gender minorities and non-minorities.

Findings

The study included over 97,000 participants, with 1.3% identifying as belonging to gender minorities and 10% identifying as sexual minorities. Adults belonging to SGM groups were, on average, younger and less likely to be married, insured, or have higher incomes compared to non-SGM adults.

After controlling for various factors, the study found that adults belonging to sexual minorities were 58% more likely to avoid care due to PCID compared to heterosexual adults, while adults belonging to gender minorities were twice as likely as cisgender adults to avoid care.

SGM participants also showed higher healthcare discrimination scores than non-SGM participants. Higher scores for healthcare discrimination were further positively correlated with higher likelihoods of avoiding care based on PCID. The avoidance was more common among those with higher discrimination experiences, indicating a dose-dependent relationship.

For example, adults from sexual minorities with high discrimination scores were more likely to avoid care (26.1%) compared to those with low scores (6.1%), with similar patterns for adults belonging to gender minorities. This highlights the impact of discrimination on care avoidance among SGM populations.

Conclusions

This study is relevant as it highlights the significant issue of care avoidance among adults belonging to SGM groups due to identity mismatches with clinicians. The findings show that SGM patients, especially those who have faced discrimination in health care, are more likely to avoid necessary care, suggesting the importance of more inclusive and affirming healthcare environments.

The strengths of the study include its large and diverse sample, making it one of the few studies to quantitatively examine identity concordance between clinicians and patients belonging to SGM groups. Additionally, the study reveals a dose-dependent relationship between healthcare discrimination and care avoidance, underscoring the importance of addressing discrimination.

However, the study has limitations. The questionnaire did not contain explicit questions about gender identity or sexual orientation related to care avoidance. Also, the sample is not fully representative of the United States population. Limited sample sizes prevented intersectional analyses across race, ethnicity, and SGM identities, which should be explored in future research.

Further studies should examine whether matching SGM patients with identity-concordant clinicians improves patient experience and health outcomes. Expanding SGM-related training for all clinicians and enacting policies to prevent discrimination are crucial next steps.