Association of Affirming Care with Chronic Disease and Preventative Care Outcomes among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults

  • Tara McKay
    Address correspondence to: Tara McKay, PhD, Department of Medicine, Health, and Society, Vanderbilt University, 2301 Vanderbilt Place, PMB 351665, Nashville TN 37235-1665.
    Department of Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee

    Department of Health Policy, Vanderbilt University, Nashville, Tennessee

    Vanderbilt LGBT+ Policy Lab, Vanderbilt University, Nashville, Tennessee.
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  • Nathaniel M. Tran
    Department of Health Policy, Vanderbilt University, Nashville, Tennessee

    Vanderbilt LGBT+ Policy Lab, Vanderbilt University, Nashville, Tennessee.
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  • Harry Barbee
    Department of Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee

    Vanderbilt LGBT+ Policy Lab, Vanderbilt University, Nashville, Tennessee.
    Search for articles by this author
  • Judy K. Min
    Department of Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee
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Published:November 29, 2022DOI:


      Experiences of discrimination and bias in healthcare contribute to health disparities for lesbian, gay, bisexual, transgender, and queer populations. To avoid discrimination, many go to great lengths to find healthcare providers who they trust and who are knowledgeable about their health needs. This study examines whether access to an affirming provider improves health outcomes for lesbian, gay, bisexual, transgender, and queer populations across a range of preventive health and chronic disease management outcomes.


      This cross-sectional study uses Poisson regression models to examine original survey data (n=1,120) from Wave 1 of the Vanderbilt University Social Networks, Aging, and Policy Study, a panel study examining older (aged 50–76 years) lesbian, gay, bisexual, transgender, and queer adults’ health and aging, collected between April 2020 and September 2021.


      Overall, access to an affirming provider is associated with greater uptake of preventive health screenings and improved management of mental health conditions. Participants with an affirming provider are more likely to have ever and recently received several types of preventive care than participants reporting a usual source of care that is not affirming, including past year provider visit, influenza vaccination, colorectal cancer screening, and HIV test. Access to an affirming provider is also associated with better management of mental health conditions.


      Inclusive care is essential for reducing health disparities among lesbian, gay, bisexual, transgender, and queer populations. Health systems can reduce disparities by expanding continuing education opportunities; adopting nondiscrimination policies for patients and employees; and ensuring that necessary care is covered by health insurance.
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        • Harvard T.H. Chan School of Public Health, NPR, and Robert Wood Johnson Foundation.
        Discrimination in America: Experiences and Views of LGBTQ Americans.
        Harvard University, Boston, MANovember 2017
        • Ceres M
        • Quinn GP
        • Loscalzo M
        • Rice D.
        Cancer screening considerations and cancer screening uptake for lesbian, gay, bisexual, and transgender persons.
        Semin Oncol Nurs. 2018; 34: 37-51
        • Barbara AM
        • Quandt SA
        • Anderson RT.
        Experiences of lesbians in the health care environment.
        Women Health. 2001; 34: 45-62
        • Martos AJ
        • Fingerhut A
        • Wilson PA
        • Meyer IH.
        Utilization of LGBT-specific clinics and providers across three cohorts of lesbian, gay, and bisexual people in the United States.
        SSM Popul Health. 2019; 9100505
        • Tuller D.
        For LGBTQ patients, high-quality care in a welcoming environment.
        Health Aff (Millwood). 2020; 39: 736-739
      1. Giano Z, Hubach RD, Meyers HJ, et al. Assessing the health care experiences of rural men who have sex with men (MSM). J Health Care Poor Underserved. 2020;31(1):235–248.

        • Keuroghlian AS
        • Ard KL
        • Makadon HJ.
        Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments.
        Sex Health. 2017; 14: 119-122
        • Obedin-Maliver J
        • Goldsmith ES
        • Stewart L
        • et al.
        Lesbian, gay, Bisexual, and transgender-related content in undergraduate medical education.
        JAMA. 2011; 306: 971-977
        • Sutter ME
        • Simmons VN
        • Sutton SK
        • et al.
        Oncologists’ experiences caring for LGBTQ patients with cancer: qualitative analysis of items on a national survey.
        Patient Educ Couns. 2021; 104: 871-876
        • Khalili J
        • Leung LB
        • Diamant AL.
        Finding the perfect doctor: identifying lesbian, gay, bisexual, and transgender-competent physicians.
        Am J Public Health. 2015; 105: 1114-1119
        • Parameshwaran V
        • Cockbain BC
        • Hillyard M
        • Price JR.
        Is the lack of specific lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) health care education in Medical School a cause for concern? Evidence from a survey of knowledge and practice among UK medical students.
        J Homosex. 2017; 64: 367-381
        • Petroll AE
        • Mosack KE.
        Physician awareness of sexual orientation and preventive health recommendations to men who have sex with men.
        Sex Transm Dis. 2011; 38: 63-67
        • Rossman K
        • Salamanca P
        • Macapagal K.
        A qualitative study examining young adults’ experiences of disclosure and nondisclosure of LGBTQ identity to health care providers.
        J Homosex. 2017; 64: 1390-1410
        • Meckler GD
        • Elliott MN
        • Kanouse DE
        • Beals KP
        • Schuster MA.
        Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth.
        Arch Pediatr Adolesc Med. 2006; 160: 1248-1254
        • Ye M
        • Kahana B
        • Kahana E
        • Xu S.
        Trust in the doctor-patient Relationship Enhances Well-being and Life Satisfaction among Older LGBTQ People.
        Innov Aging. 2018; 2: 123
        • Stein GL
        • Bonuck KA.
        Original research: physician-patient relationships among the lesbian and gay community.
        J Gay Lesbian Med Assoc. 2001; 5: 87-93
        • Durso LE
        • Meyer IH.
        Patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbians, gay men, and bisexuals.
        Sex Res Social Policy. 2013; 10: 35-42
        • Kamen CS
        • Smith-Stoner M
        • Heckler CE
        • Flannery M
        • Margolies L.
        Social support, self-rated health, and lesbian, gay, bisexual, and transgender identity disclosure to cancer care providers.
        Oncol Nurs Forum. 2015; 42: 44-51
        • Boehmer U
        • Case P.
        Physicians don't ask, sometimes patients tell: disclosure of sexual orientation among women with breast carcinoma.
        Cancer. 2004; 101: 1882-1889
        • McKay T
        • Akré ER
        • Henne J
        • Kari N
        • Conway A
        • Gothelf I
        LGBTQ. LGBTQ+ Affirming care may increase awareness and understanding of undetectable = untransmittable among midlife and older gay and bisexual men in the U.S. south.
        Int J Environ Res Public Health. 2022; 19: 10534
        • DiLeo R
        • Borkowski N
        • O'Connor SJ
        • Datti P
        • Weech-Maldonado R
        The relationship between “leader in LGBT healthcare equality” designation and hospitals’ patient experience scores.
        J Healthc Manag. 2020; 65: 366-377
        • Katz A.A.
        Gay and lesbian patients with cancer.
        Oncol Nurs Forum. 2009; 36: 203-207
        • Katz A.
        Gay and lesbian patients with cancer.
        in: Mulhall JP Incrocci L Goldstein I Rosen R Cancer and Sexual Health. Current Clinical Urology. Humana Press, Totowa, NJ2011: 397-403
        • Cloyes KG
        • Hull W
        • Davis A.
        Palliative and end-of-life care for lesbian, gay, bisexual, and transgender (LGBT) cancer patients and their caregivers.
        Semin Oncol Nurs. 2018; 34: 60-71
        • Makadon HJ.
        Improving health care for the lesbian and gay communities.
        N Engl J Med. 2006; 354: 895-897
        • Mayer KH
        • Bradford JB
        • Makadon HJ
        • Stall R
        • Goldhammer H
        • Landers S.
        Sexual and gender minority health: what we know and what needs to be done.
        Am J Public Health. 2008; 98: 989-995
        • Romanelli M
        • Lindsey MA.
        Patterns of healthcare discrimination among transgender help-seekers.
        Am J Prev Med. 2020; 58: e123-e131
        • Ng BE
        • Moore D
        • Michelow W
        • et al.
        Relationship between disclosure of same-sex sexual activity to providers, HIV diagnosis and sexual health services for men who have sex with men in Vancouver, Canada.
        Can J Public Health. 2014; 105: e186-e191
        • Stupiansky NW
        • Liau A
        • Rosenberger J
        • et al.
        Young Men's disclosure of same sex behaviors to healthcare providers and the impact on health: results from a U.S. national sample of young men who have sex with men.
        AIDS Patient Care STDS. 2017; 31: 342-347
        • Metheny N
        • Stephenson R.
        Disclosure of sexual orientation and uptake of HIV testing and hepatitis vaccination for rural men who have sex with men.
        Ann Fam Med. 2016; 14: 155-158
        • Griffin M
        • Krause KD
        • Kapadia F
        • Halkitis PN.
        A qualitative investigation of healthcare engagement among young adult gay men in New York City: a P18 cohort substudy.
        LGBT Health. 2018; 5: 368-374
      2. Koehler A, Strauss B, Briken P, Szuecs D, Nieder TO. Centralized and decentralized delivery of transgender health care services: a systematic review and a global expert survey in 39 countries. Front Endocrinol. 2021;12:717914.

        • Eliason MJ
        • Dibble SL
        • Robertson PA.
        Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace.
        J Homosex. 2011; 58: 1355-1371
        • Seay J
        • Mitteldorf D
        • Yankie A
        • Pirl WF
        • Kobetz E
        • Schlumbrecht M.
        Survivorship care needs among LGBT cancer survivors.
        J Psychosoc Oncol. 2018; 36: 393-405
        • Fredriksen-Goldsen KI
        • Kim HJ
        • Barkan SE
        • Muraco A
        • Hoy-Ellis CP.
        Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study.
        Am J Public Health. 2013; 103: 1802-1809
        • Fredriksen-Goldsen KI
        • Kim HJ
        • Bryan AEB
        • Shiu C
        • Emlet CA.
        The cascading effects of marginalization and pathways of resilience in attaining Good Health among LGBT older adults.
        Gerontologist. 2017; 57: S72-S83
        • Gonzales G
        • Henning-Smith C.
        Disparities in health and disability among older adults in same-sex cohabiting relationships.
        J Aging Health. 2015; 27: 432-453
        • Fredriksen-Goldsen KI
        • Cook-Daniels L
        • Kim HJ
        • et al.
        Physical and mental health of transgender older adults: an at-risk and underserved population.
        Gerontologist. 2014; 54: 488-500
        • Correro AN
        • Nielson KA.
        A review of minority stress as a risk factor for cognitive decline in lesbian, gay, bisexual, and transgender (LGBT) elders.
        J Gay Lesbian Ment Health. 2020; 24: 2-19
        • Reisner SL
        • Pardo ST
        • Gamarel KE
        • White Hughto JMW
        • Pardee DJ
        • Keo-Meier CL
        Substance use to cope with stigma in healthcare among U.S. female-to-male trans masculine adults.
        LGBT Health. 2015; 2: 324-332
        • Institute of Medicine (US) Committee on Lesbian
        Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people: building a foundation for a better understanding.
        National Academies Press (US), Washington (DC)2011
        • Hasenbush A
        • Flores AR
        • Kastanis A
        • Sears B
        • Gates GJ.
        The LGBT divide: a data portrait of LGBT people in the midwestern, mountain & southern states.
        The Williams Institute, Washington, DCDecember 2014
      3. Equality maps: healthcare laws and policies. Movement Advancement Project. Updated 22 June 2022. Accessed 20 July 2022.

      4. Household pulse survey data tables. U.S. Census Bureau. Updated 20 October 2021. Accessed July 7, 2022.

      5. A and B recommendations. United States Preventive Services Task Force. Updated May 2021. Accessed March 24, 2022.

      6. Hughes L, Shireman TI, Hughto J. Privately insured transgender people are at elevated risk for chronic conditions compared with cisgender counterparts. Health Aff (Millwood). 2021;40(9):1440–1448.

        • Fredriksen-Goldsen KI
        • Kim HJ
        • Shui C
        • Bryan AEB.
        Chronic health conditions and key health indicators among lesbian, gay, and bisexual older U.S. adults, 2013–2014.
        Am J Public Health. 2017; 107: 1332-1338
        • McNutt LA
        • Wu C
        • Xue X
        • Hafner JP.
        Estimating the relative risk in cohort studies and clinical trials of common outcomes.
        Am J Epidemiol. 2003; 157: 940-943
        • Zou G.
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Tordoff DM
        • Wanta JW
        • Collin A
        • Stepney C
        • Inwards-Breland DJ
        • Ahrens K
        Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care.
        JAMA Netw Open. 2022; 5e220978
        • Turban JL
        • King D
        • Carswell JM
        • Keuroghlian AS.
        Pubertal suppression for transgender youth and risk of suicidal ideation.
        Pediatrics. 2020; 145e20191725
        • Chew D
        • Anderson J
        • Williams K
        • May T
        • Pang K.
        Hormonal treatment in young people with gender dysphoria: a systematic review.
        Pediatrics. 2018; 141e20173742
        • de Vries ALC
        • McGuire JK
        • Steensma TD
        • Wagenaar ECF
        • Doreleijers TAH
        • Cohen-Kettenis PT.
        Young adult psychological outcome after puberty suppression and gender reassignment.
        Pediatrics. 2014; 134: 696-704
        • CSt Amand
        • Fitzgerald KM
        • Pardo ST
        • Babcock J.
        The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals.
        J Gay Lesbian Ment Health. 2011; 15: 281-299
        • Centers for Disease Control and Prevention
        HIV in the Southern United States. 2019; 29: 1-4
      7. Healthcare equality index 2020. Human Rights Campaign. Accessed November 22, 2022.

      8. Colorectal cancer screening: cancer trends progress report. National Cancer Institute. Updated April 2022. Accessed July 13, 2022.

        • Alsan M
        • Garrick O
        • Graziani G.
        Does diversity matter for health? Experimental evidence from Oakland.
        Am Econ Rev. 2019; 109: 4071-4111
        • Agénor M
        • Krieger N
        • Austin SB
        • Haneuse S
        • Gottlieb BR.
        At the intersection of sexual orientation, race/ethnicity, and cervical cancer screening: assessing Pap test use disparities by sex of sexual partners among black, Latina, and white U.S. women.
        Soc Sci Med. 2014; 116: 110-118
        • Grasso C
        • Goldhammer H
        • Thompson J
        • Keuroghlian AS.
        Optimizing gender-affirming medical care through anatomical inventories, clinical decision support, and population health management in electronic health record systems.
        J Am Med Inform Assoc. 2021; 28: 2531-2535
        • Vermund SH
        • Wilson CM.
        Barriers to HIV testing–where next?.
        Lancet. 2002; 360: 1186-1187
        • Rayment M
        • Thornton A
        • Mandalia S
        • et al.
        HIV testing in non-traditional settings - the HINTS study: a multi-centre observational study of feasibility and acceptability.
        PLoS One. 2012; 7: e39530
        • Wee CC
        • McCarthy EP
        • Phillips RS.
        Factors associated with colon cancer screening: the role of patient factors and physician counseling.
        Prev Med. 2005; 41: 23-29
        • Kirkøen B
        • Berstad P
        • Botteri E
        • et al.
        Acceptability of two colorectal cancer screening tests: pain as a key determinant in sigmoidoscopy.
        Endoscopy. 2017; 49: 1075-1086
        • Kruk M
        • Matsick JL.
        A taxonomy of identity safety cues based on gender and race: from a promising past to an intersectional and translational future.
        Transl Issues Psychol Sci. 2021; 7: 487-510
        • Gonzales G
        • Zinone R.
        Cancer diagnoses among lesbian, gay, and bisexual adults: results from the 2013–2016 National Health Interview Survey.
        Cancer Causes Control. 2018; 29: 845-854
        • MetLife
        Still Out, Still Aging: The Metlife Study of Lesbian, Gay, Bisexual, and Transgender Baby Boomers.
        MetLife, Westport, CT2010
      9. Creating an LGBTQ-friendly practice. American Medical Association. Updated 2021. Accessed 8 August 2022.

        • Cahill S
        • Makadon H.
        Sexual orientation and gender identity data collection in clinical settings and in electronic health records: a key to ending LGBT health disparities.
        LGBT Health. 2014; 1: 34-41
      10. Gay & Lesbian Medical Association. Guidelines for care of lesbian, gay, bisexual, and transgender patients. San Francisco, CA: Gay & Lesbian Medical Association. Published 2006. Accessed July 15, 2022.

        • Wilkerson JM
        • Rybicki S
        • Barber CA
        • Smolenski DJ.
        Creating a culturally competent clinical environment for LGBT patients.
        J Gay Lesbian Soc Serv. 2011; 23: 376-394
        • McClain Z
        • Hawkins LA
        • Yehia BR.
        Creating welcoming spaces for lesbian, gay, bisexual, and transgender (LGBT) patients: an evaluation of the health care environment.
        J Homosex. 2016; 63: 387-393
        • Pratt-Chapman ML
        • Eckstrand K
        • Robinson A
        • et al.
        Developing standards for cultural competency training for health care providers to care for lesbian, gay, bisexual, transgender, queer, intersex, and asexual persons: consensus recommendations from a national panel.
        LGBT Health. 2022; 9: 340-347
        • Nowaskie DZ
        • Sewell DD.
        Assessing the LGBT cultural competency of dementia care providers.
        Alzheimers Dement (N Y). 2021; 7: e12137
        • Cornelius JB
        • Carrick J.
        A survey of nursing students’ knowledge of and attitudes toward LGBT health care concerns.
        Nurs Educ Perspect. 2015; 36: 176-178
        • Moll J
        • Krieger P
        • Moreno-Walton L
        • et al.
        The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know?.
        Acad Emerg Med. 2014; 21: 608-611
        • Greenwood BN
        • Carnahan S
        • Huang L.
        Patient-physician gender concordance and increased mortality among female heart attack patients.
        Proc Natl Acad Sci U S A. 2018; 115: 8569-8574
        • Laveist TA
        • Nuru-Jeter A.
        Is doctor-patient race concordance associated with greater satisfaction with care?.
        J Health Soc Behav. 2002; 43: 296-306
        • Wallis CJD
        • Jerath A
        • Coburn N
        • et al.
        Association of surgeon-patient sex concordance with postoperative outcomes.
        JAMA Surg. 2022; 157: 146-156
        • Romanelli M
        • Hudson KD.
        Individual and systemic barriers to health care: perspectives of lesbian, gay, bisexual, and transgender adults.
        Am J Orthopsychiatry. 2017; 87: 714-728
        • Gonzales G
        • McKay T
        • Carpenter CS.
        Disparities in health insurance coverage and access to care for children by mother's sexual orientation.
        Matern Child Health J. 2020; 24: 630-639