A nurse might ask a woman at an OB-GYN prenatal care appointment if her husband is with her, only to find out the woman’s female partner is with her. A doctor may ask a transgender man how many female sexual partners he has had, and the man says none, but the actuality is he has had more than 20 male partners.
Situations like these may cause gay, lesbian and other sexual and gender minority individuals to feel their health care providers are not being inclusive, or they may even feel discriminated against. These situations may even cause them to avoid returning for future appointments and care, which can imperil the health of this population that is already higher-risk for physical and mental problems compared to heterosexual individuals.
Researchers from the College of Nursing are working to advance health outcomes in sexual and gender minority individuals, who face disparities in access to care compared to heterosexual individuals. The researchers, Britney Wardecker, Cara Exten, and Oluwamuyiwa Adebayo, hope their work will help providers better understand the needs, challenges, and resilience of these groups.
“Many LGBTQ people face difficult health challenges as a result, to some extent, of stigma and discrimination,” Wardecker said. “There’s a vicious cycle with health disparities and feeling like you can’t access the care you need. If people are having more health troubles, they will need to see health care providers more. But if they avoid seeing a health care provider, those disparities will worsen.”
Wardecker, Exten and Adebayo are assistant professors on the tenure-track faculty in the college. Their research is expanding the body of knowledge about sexual and gender minorities and how stressors, stigma and discrimination can affect their outcomes and care.
Wardecker’s research primarily focuses on LGBTQ health and wellness, and her second area examines healthy aging in later adulthood. She said the intersection of her research is on the health and experiences of LGBTQ older adults, or those ages 50 and older.
“This group has had a particularly tumultuous past with respect to their sexual orientation,” said Wardecker, noting they came of age as the LGBT movement began and likely faced family rejection and a lack of social support. “If someone is repeatedly discriminated against across their life, how does that accumulate to affect the stress response system in a negative way?”
Wardecker has published research that identifies ways health care providers can better serve these LGBTQ older adults. She said inclusive or welcoming signs, as recommended by the American Medical Association, are not enough and their effect has not been adequately tested. More importantly, providers should focus on their interactions and mindfulness.
“Let’s say someone brings a person with them into a doctor’s appointment,” Wardecker said. “Don’t assume it’s their husband or wife with them. Allow people to identify these individuals in the way that they want to and then use that language to refer to them.”
Another ongoing research paper investigates the kinds of daily stressors that can lead to long-term health effects for LGBTQ individuals. She said outright acts of discrimination, including physical attacks or graffiti vandalism, are obvious triggers of stress, but daily sources are an important yet understudied possible source. For instance, she said stress can come from microaggressions at work.
Wardecker said she has found in her work that lesbian, gay and bisexual individuals experience more daily stressors compared to heterosexual individuals, and these daily stressors are associated with daily physical symptoms, such as headaches.
“LGB individuals experience more discrimination and stress over the course of a week,” Wardecker said. “That goes hand in hand with minor conditions like headaches, being more tired or inflammation that can lead to long-term health consequences over time.”
Wardecker found similarities about life satisfaction of adult bisexual men and women in a study she wrote in Archives of Sexual Behavior in 2019. Wardecker said older bisexual individuals experience more negative mental and physical health outcomes compared to both heterosexual individuals and other sexual minorities. She said understanding bisexuals’ aging processes is critical to help reduce disparities and promote healthy aging for sexual minorities.
Wardecker is writing a grant to study whether LGBT individuals have advance care directives, such as living wills, powers of attorney or do-not-resuscitate orders. She said because LGBT individuals are more likely than non-LGBT individuals to have chronic health conditions, it may be even more critical for LGBT adults to have plans in place so their end-of-life wishes can be fulfilled and respected. .
“It is beneficial for doctors and clinicians to know those decisions,” Wardecker said. “LGTBQ older adults may not have these plans in place because of various barriers to healthc are access and/or because they are less likely to be married or to have children.”
Where Wardecker’s research focuses on older individuals, Exten’s interests are on health-based outcomes among younger people. Exten, who is an infectious disease epidemiologist, is focusing her research on behaviors as the potential pathway by which discrimination leads to health outcomes.
“I'm trying to understand how discrimination at the daily level may be related to individual behavior,” Exten said. “Discrimination occurs at a personal level, at the familial level, at the service level. It's happening in almost every level of life, and that creates such stress that they are at increased risk for poor health outcomes.”
Discrimination may lead to risky or unhealthy behaviors, perhaps to avoid high-discrimination situations or as a coping mechanism, she said.
“If someone experiences discrimination in their neighborhood, are they less likely to exercise because they don't feel safe?” she said. “Do they feel comfortable going on a walk, going on a run, or do they stay home – and how do those factors contribute to their risk for cardiovascular disease?”
Exten has published several papers using nationally representative data documenting disparities affecting sexual minority populations with respect to a variety of outcomes: Sexual minority populations have higher rates of depression, anxiety, substance abuse, cardiovascular disease, and STD infections, for instance. One paper was published in 2019 in the Annals of Epidemiology and another in 2018 in Drug and Alcohol Dependence.
Exten co-authored a study in Prevention Science in 2019 that found that sexual minorities younger than 30 who experienced anti-LGB discrimination were more likely to experience suicidal behavior, highlighting the dangerous consequences of anti-LGB discrimination.
Exten is in the early stages of a new study that will closely examine discrimination experiences, behaviors, and health status of young adult sexual minorities throughout Pennsylvania. The participants are asked to fill out a survey for 30 days documenting, for instance, stress, how they spent their time, discrimination, etc. The participants will log their health behaviors, too -- sleeping, eating, exercise, alcohol intake or smoking, or sex with a new partner and more. Exten hopes this will help a picture emerge of how behaviors may vary after experiencing discrimination.
Exten is collaborating on a similar project with Adebayo, whose focus is on sexually transmitted infections. The two will closely examine the health status of transgender populations in Pennsylvania, with a focus on understanding barriers to health care.
“Transgender populations have been identified as a population at high risk to experience low access to health care and low health care usage,” Exten said. “But not many have looked at this population in rural areas.”
Exten said transgender populations, on average, are at high risk of poor health outcomes, including HIV, substance abuse, and negative mental health. Identifying the barriers that prevent individuals from seeking and access health care is a critical step to improving health among transgender individuals, Exten said.
“What ends up happening, that person feels less inclined to open up about their sex orientation or behaviors,” Adebayo said. “Secondly they leave that clinician visit without any resources or any help.”
“The resources we have are still catching up to the sexual gender and minority education – access to care, ability of clinicians to meet needs,” Adebayo said. “The best we’re doing is people are talking about it.”
In another partnership among this group, Adebayo is collaborating with Wardecker to look at the mechanisms to HIV care of men who have sex with men who are Black and Hispanic. Adebayo said racial and sexual minorities will access health care differently, and she and Wardecker hope to understand that to improve care.
Adebayo is also looking at the differences between heterosexual and sexual and gender minority students in how they see different barriers in sexual transmitted infections. She said it will help them understand what it takes for these different groups to initiate testing.
“We need to be aware of the needs they have and structure the resources,” she said.
Adebayo called on health care professionals to improve care and no longer ignore the needs of these individuals.
“Imagine going to get care and the person tells you, ‘I’m sorry, I have no training to deal with people like you,’” she said. “How do you focus only on one group of people? How do you not let a significant portion of the population get the care they need?”