HEALTH DISPARITIES AND HEALTH RISK FACTORS

Ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location are all factors that contribute to an individual’s ability to achieve good health. Disparity refers to a health outcome that is seen to a greater or lesser extent in one population relative to another population. Risk factor refers to a behavior or condition that increases a person’s chance of developing a disease or health condition. This may include social and environmental factors (Medina-Martinez et al., 2021). The LGBTQ+ population is diverse in terms of race, ethnicity, disability, and socioeconomic status. Therefore, risk factors and disparities in each patient will vary depending on these individual factors. (See discussion below on specific population groups.)

Research has uncovered that LGBTQ+ individuals often face health disparities related to societal stigma, discrimination, and denial of civil and human rights in some manner. Discrimination has been linked to higher rates of psychiatric disorders, substance abuse disorders, and suicide. Violence and victimization are also more common and have life-long consequences to the individual and the community as a whole. Personal, family, and social acceptance of an individual’s sexual orientation and gender identity often affects these individuals’ mental health and personal safety (Medina-Martinez et al., 2021).

Individuals who identify as LGBTQ+ may also experience minority stress. Minority stress theory connects health disparities among individuals to stressors induced by a hostile, homophobic culture in society as a whole. This often results in experiences of prejudice, internal expectations of rejection, and internalized homophobia. Aspects of minority stress, including the perception of prejudice, stigma, or rejection, are associated with higher rates of depression and dysfunctional coping strategies (Hoy-Ellis, 2021).

LGBTQ+ populations experience a greater prevalence of mental health distress and diagnosis, such as:

• Anxiety and depression
• Suicidal ideation and attempts
• Other forms of emotional, physical, and sexual trauma (such as intimate partner violence)
  (Hoy-Ellis, 2021; Coleman et al., 2022)

Gay, lesbian, and bisexual adolescents and young adults have higher rates of tobacco and alcohol use, substance abuse, eating disorders, and risky sexual behaviors. This may be due to a higher level of psychological distress (CDC, 2022d; The Trevor Project, 2020, 2022).

Men Who Have Sex with Men (MSM)

The most researched health disparity among MSM is HIV/AIDS incidence and prevalence. In 2018, 81% of new HIV cases among men occurred in men who had sex with men (CDC, 2020). Gay, bisexual, and men who have sex with men have also been found to be at increased risk of other sexually transmitted infections (STIs) (CDC, 2022a), including:

• Syphilis
• Gonorrhea
• Chlamydia
• Human papillomavirus (HPV)
• Hepatitis A and B

Gay men are also at an increased risk of cancers, including prostate, testicular, anal, and colon, which may be related to limited cancer screening and prevention services for this population (Domogauer et al., 2022). Moreover, men who have sex with men are also at higher risk for tobacco and drug use and depression (CDC, 2022b).

CLINICAL IMPLICATIONS

When providing care for men who have sex with men, clinicians and case managers should not assume that the individual is engaged in actions that increase the risk for certain disorders; a history should first be performed to understand the individual’s risk (HEC, 2021). Understanding the risk factors and health disparities for MSM, it is important to address the unique clinical concerns for this population through:

• Regular assessment and screening for STIs and HIV
• Routine vaccination for hepatitis A, hepatitis B, and HPV
• Prevention and screening for prostate, testicular, anal, oral (head and neck), and colon cancers
  (CDC, 2022a)

Women Who Have Sex with Women (WSW)

Lesbian and bisexual women are more likely to be obese and to use tobacco and alcohol than heterosexual women. Stress may be a contributing factor to the increased substance use or abuse in this population. WSW are also at increased risk for depression and anxiety disorders and are less likely to receive routine reproductive care. Lesbian women are also less likely to access cancer screening and prevention services (Office on Women’s Health, 2020; Open Access Government, 2020; ACS, 2021).

Lesbian women may be at a higher risk for uterine, breast, cervical, endometrial, and ovarian cancers for some of the factors listed above (ACS, 2021). Also, lesbians have traditionally been less likely to bear children, and hormones released during pregnancy and breastfeeding are believed to protect women against breast, endometrial, and ovarian cancers (WebMD, 2020).

CLINICAL IMPLICATIONS

Clinicians and case managers working with women who have sex with women should carefully assess and address the multiple risks that this population faces by providing:

• Preventive and wellness care to prevent or treat tobacco use/abuse and alcohol use/abuse
• Screening and early identification of behavioral health concerns such as depression or anxiety
• Regular preventive care and screening for uterine, breast, cervical, endometrial, and ovarian cancers
• Programs for healthy weight and exercise
  (WebMD, 2020)

Transgender and Gender Diverse

Transgender individuals often face victimization, violence, and minority stress, and they are less likely to have access to health insurance for a variety of reasons. Transgender individuals have a higher prevalence of:

• HIV
• Sexually transmitted infections (STIs)
• Behavioral health disorders
• Suicide
  (CDC, 2022c; CDC, 2021; NAMI, 2022)

CLINICAL IMPLICATIONS

Caring for transgender patients therefore includes screening for the following risks, as appropriate:

• Access to appropriate health insurance
• Violence
• Minority stress
• HIV
• STIs
• Suicide
• Behavioral health disorders
  (Caughey et al., 2021; Eder et al., 2021; Goldsmith & Bell, 2022)

Adolescents and Young Adults

Many concerns may impact the health and well-being of an LGBTQ+ individual. This is especially true for adolescents, who are in the process of navigating developmental milestones along with sexual orientation and gender identity.

Young adults who “come out” may be faced with bullying from their peers or family rejection. LGBTQ+ youth have a high rate of substance abuse, STIs, and homelessness (Hao et al., 2021). They are more prone to have an increased risk of depression, suicidal ideation, and substance use, including tobacco, alcohol, cannabis, cocaine, ecstasy, and heroin (The Trevor Project, 2020, 2021).

Research has shown that LGBTQ+ adolescents and young adults with family acceptance have greater self-esteem, more social support, and better health outcomes. This acceptance also reduces the risk of substance abuse, depression, and suicide (Delphin-Rittmon, 2022).

CLINICAL IMPLICATIONS

Clinicians and case managers working with this population should pay careful attention to subtle clues and risk factors of each individual, as adolescents and young adults may be especially reticent to discuss their concerns. Careful assessment focuses on:

• Evidence or risk of bullying
• Dysfunctional family dynamics
• Substance abuse risks
• Depression screening
• Suicide risks
• STIs screening
• HPV vaccination
• Home living conditions
  (Hao et al., 2021; Eder et al., 2021)