Snapshot

          Systemic discrimination and stigma have profoundly impacted the ability of LGBTQIA+ patients to access high-quality, timely healthcare in the United States. More than 17% of LGBTQIA+ Americans do not have any form of health insurance coverage, compared to only 12% of non-LGBTQIA+ Americans. Substandard medical care due to discrimination or outright denial of care is compounded by existing health disparities and healthcare concerns unique to LGBTQIA+ Americans.
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LGBTQIA+ Population in the US: Diverse & Growing

At least 5.6% of adult Americans identity lesbian, gay, bisexual, transgender, queer, questioning, or intersex (LGBTQIA+)—more than 18 million people. This includes about 2 million Americans who identify as transgender. Younger Americans are more likely to identify as LGBTQIA+, with 9.1% of Millennials (adults ages 24-39) identifying as LGBTQIA+ compared to only 3.8% of Gen X (adults ages 40-55). One in six adult Gen Z Americans (ages 18-24) identify as LGBTQIA+, indicating the LGBTQIA+ population will continue to grow over time.
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Source: GALLUP

People of color are more likely than whites to identify as LGBTQIA+. 4% percent of whites identify as LGBTQIA+, while 6.1% of Latinx individuals, 5% of Black Americans, and 4.9% of Asian Americans identify as LGBTQIA+. Lower income people are more likely to identify as LGBTQIA+ than higher income people. Of individuals from households making less than $36,000 a year, 6.2% identify as LGBTQIA+, while only 3.9% of individuals from households making $90,000 a year or more identify as LGBTQIA+.

Although the highest concentrations of LGBTQIA+ Americans live in urban settings, between 2.9-3.8 million LGBTQIA+ Americans live in rural areas—up to 5% of the total rural population and 20% of the LGBTQIA+ population in the United States.
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Healthcare Concerns

LGBTQIA+ Americans face many of the same healthcare concerns as non-LGBTQIA+ individuals, but experience higher rates of certain chronic conditions including cancer, diabetes, obesity, and earlier onset and higher prevalence of mental and physical disabilities. More than 1.4 million LGBTQIA+ Americans are living with diabetes. Additionally, LGBTQIA+ Americans are more likely to smoke or use tobacco products, at 1.5-2.5 times the rate of non-LGBTQIA+ Americans, putting the population at elevated risk for a host of downstream tobacco-related health conditions. Notably, LGBTQIA+ individuals are less likely to receive preventative services for many chronic health conditions including cancer, such as routine and annual screenings like pap smears, mammograms, colonoscopies, and testicular exams. Men who have sex with men (MSM) and transgender women are disproportionately affected by HIV/AIDS and other sexually transmitted infections (STIs), even more so in communities of color. One in two Black MSM and one in four Latinx MSM will contract HIV in their lifetime. Older LGBTQIA+ Americans are also impacted by discrimination and mobility issues. Increased isolation and lack of social services mean older adults are less likely to receive care for chronic health conditions.
Americans who identify as LGBTQIA+ have the highest rates of substance use, including alcohol, tobacco and other drug use as well as overall higher rates of substance use disorder (SUD). Additionally, LGBTQIA+ Americans experience higher rates of mental health concerns, most likely due to systemic discrimination—including higher rates of psychiatric disorders, substance abuse, and heightened risk for suicide.
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Discrimination in Healthcare

Healthcare discrimination against LGBTQIA+ patients is well documented. When sick or injured, LGBTQIA+ Americans are more likely to avoid or postpone seeking medical care—29% of lesbian, gay and bisexual individuals and 73% of transgender Americans report they believe they will be treated differently by healthcare providers when seeking medical care because of their identity. Recent US surveys indicate 19% of transgender Americans have been refused care due to their gender identity, with even higher numbers of transgender people of color reporting refusal of care by a medical provider. Ongoing harassment and even violence in medical settings is also widely reported, with 28% of transgender Americans reporting harassment and 2% reporting physical violence. 
More subtle yet equally harmful is lack of provider knowledge, with over 50% of transgender patients surveyed reporting they have had to teach their medical care providers about LGBTQIA+-relevant healthcare. Even among providers who self-identify as competent in providing care for LGBTQIA+ patients, the majority of clinicians rarely or never talked to their patients about sexual orientation or gender identity due to the belief that these identities were not relevant to medical care or not knowing appropriate language to use in conversations with patients.
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Telehealth for LGBTQIA+ Populations

For LGBTQIA+ Americans, increased telehealth options do more than just increase patient satisfaction, they help mitigate barriers to care.
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3 Key Ways Telehealth Increases Access to Care for LGBTQIA+ People
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1. Expands geographic access to care, particularly for the 20% of LGBTQIA+ Americans living in rural areas.

LGBTQIA+ individuals who live in rural areas are more likely to experience discrimination and stigma, including homophobic speech, job discrimination, and property damage compared to those living in urban areas. Rural areas have fewer LGBTQIA+-identified healthcare providers and fewer healthcare providers trained to provide culturally competent, affirming care for LGBTQIA+ patients. LGBTQIA+ Americans living in rural locations are less likely to access primary care due to stigma and lack of comfort disclosing sexual orientation or gender identity to providers. This directly impacts engagement with preventative healthcare services and the monitoring of chronic health conditions that disproportionately burden LGBTQIA+ Americans.
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Telehealth gives healthcare providers with specialist training ability to provide consultations and expertise over a greater geographic area to people in rural or other low-resource environments, where many lower-income and un- and under-insured LGBTQIA+ Americans reside.
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For example, in a rural setting there may not be a local clinician experienced in providing pre-exposure prophylaxis (or PrEP) prescription, an important medication regimen to prevent HIV infection in individuals at risk, which includes members of the LGBTQIA+ community.
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2. Connects LGBTQIA+ patients to competent and affirming care providers and lowers risk of discriminatory healthcare interactions

Many LGBTQIA+ people have difficulty finding providers who are trained and experienced in providing competent care for LGBTQIA+ populations. There are health conditions that disproportionately impact the LGBTQIA+ community, particularly around sensitive healthcare issues like mental health, substance use disorders, reproductive health care, and sexual health. Telehealth can connect affirming clinicians with patients instantly, regardless of geography. Telehealth services can mitigate the risk of LGBTQIA+ patients coming in contact with staff or other personnel at a healthcare setting who may be harmful to or unaware of the needs of these patients, or even overtly discriminatory.
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3. Makes healthcare more accessible for younger LGBTQIA+ Americans.

Millennials and Gen Z are more likely to identify as LGBTQIA+ than their older counterparts. Younger Americans are more likely to seek out and be satisfied by telehealth services. Asynchronous care and messaging with a healthcare provider may even be preferred for sensitive health topics, including sexual health. Even before the COVID-19 pandemic rapidly expanded access to telehealth services, people ages 31 – 40 age accounted for 21% of all telehealth claims between 2014-2018. Virtual services may be necessary for individuals who experience housing insecurity or homelessness, which disproportionately affects LGBTQIA+ adolescents and young adults. Telehealth services for key young adult health concerns, including sexual health, substance use disorders, and telepsychiatry to manage mental health conditions including depression, anxiety, and eating disorders in young people have proven extremely successful. Telehealth gives younger patients more autonomy over seeking care, with less reliance on parents or other adults to travel to provider visits, and more direct access to healthcare providers on their own terms. Younger patients preferred the privacy and ease of using a smartphone, tablet or laptop to connect with a provider.
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Conclusion

The COVID-19 pandemic and public health crisis has exacerbated existing healthcare disparities for LGBTQIA+ Americans. Simultaneously, telehealth expanded the range of healthcare concerns that could be handled by a provider via phone or video at much lower cost. For lower-income LGBTQIA+ Americans and the 17% of LGBTQIA+ Americans without medical insurance, cost savings can make the difference in accessing life-saving medical care. The TEC champions the need to scale up telehealth systems in all areas of medicine and for all patients, but it can be even more urgent for LGBTQIA+ Americans who experience a greater burden of poor health and existing disparities in access to healthcare.
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Authors
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Moira Kyweluk, PhD, MPH (she/her)

Dr. Kyweluk (she/her) is the founder of Third Space Research, a research consultancy focused on public & private sector LGBTQIA+ health. She holds a PhD in Medical Anthropology from Northwestern University, a Master of Public Health from Northwestern Feinberg School of Medicine, and a Bachelor’s in Anthropology (Honors) from Brown University. Her work is featured in the academic and popular press including Everyday Health, Technology Today, and Consumer Affairs.
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Funke Sangodeyi, PhD (she/her)

Dr. Sangodeyi (she/her) is the founder of Episteme Research & Strategy, LLC, a boutique research, insights and strategy consultancy with special expertise in healthcare for underserved communities. She holds a PhD in History of Science & Medicine from Harvard University, an MPhil in History and Philosophy of Science from University of Cambridge, and a Bachelor’s in Molecular and Cellular Biology from Harvard University.
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