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HealthLGBTQ Research and Evaluation

Introduction

The National Coalition for LGBTQ Health administered the State of LGBTQ Health™ Second Annual National Survey to identify the “state of” healthcare for LGBTQ communities. The survey’s insights will be used to optimize the education and training of the LGBTQ healthcare workforce, and to better inform LGBTQ health advocacy, education, research, and training activities.

LGBTQ individuals are disproportionately impacted by a wide range of health threats when compared with their heterosexual or cisgender peers—the consequences of which are compounded by anti-LGBTQ discrimination and other systemic barriers to accessing healthcare services prevalent across location and setting in the United States.1 LGBTQ people are more likely to report poor physical and mental health than the general population, including increased incidence of HIV and other sexually transmitted infections (STIs), long-term conditions such as arthritis and chronic fatigue, and elevated risk of depression, anxiety, and other mental illness.2, 3 Transgender (Trans) and gender non-conforming (GNC) people and LGBTQ youth are particularly at risk. Trans and GNC individuals are far more likely than their cisgender counterparts to self-report poor health, disability, and activity-limited days, and a recent study demonstrated that over 40% of LGBTQ youth have seriously considered suicide in the past year.4, 5

The LGBTQ community is a priority audience for healthcare providers and programs due to these clear and significant health disparities and the disproportionate burden of disease faced by the community. Yet, despite the urgent need for greater allocation of resources to support LGBTQ health, healthcare providers nationwide continually report feeling unprepared to meet the needs of their LGBTQ clients and patients.6

When asked what the State of LGBTQ health care is in one word, respondents primarily stated “lacking” and “poor,” followed by “improving,” “fragile,” and “inadequate,” suggesting that LGBTQ health care is in crisis.

“In one word, what is the state of LGBTQ health?”

The Second Annual State of LGBTQ Health National Survey, National Coalition for LGBTQ Health

Key Findings

The Second Annual State of LGBTQ Health National Survey engaged 1,023 diverse and representative healthcare providers, spanning a broad spectrum of racial, ethnic, and sexual identities and hailing from various geographic, educational, and income backgrounds. Notably, the demographics of the survey participants closely mirrored the current composition of healthcare professionals in the United States.

Key findings from this report provide an overview of the insights gained by the survey, presenting current challenges, successes, and areas of improvement in LGBTQ health care:

  • Cultural competency confidence: Over 80% of respondents exhibit confidence in using culturally appropriate terminology when communicating with LGBTQ patients to foster a more welcoming environment.
  • Elevating LGBTQ-centered care: Requires strategic steps such as recruiting sensitive staff, providing comprehensive training, and collaborating with experienced providers.
  • Advocacy priorities: Centered on vital issues including LGBTQ equality, strong gender-affirming care protections, and ensuring affordable housing for LGBTQ individuals.
  • Lack of awareness of anti-LGBTQ bills persists: More than half of respondents acknowledge the impact on their patients, yet less than half are fully aware of the specific legal challenges.
  • Training needs for LGBTQ providers: Encompass battling stigma, creating inclusive spaces, and addressing health disparities.
  • Barriers to LGBTQ health care: include pervasive stigma, distrust in the healthcare system, mental health challenges, cost constraints, and insurance issues.

These implications should guide healthcare organizations, policymakers, and advocacy groups in developing targeted strategies and initiatives to advance LGBTQ health care and reduce disparities in the United States.

How Do LGBTQ Health Centers Serve the Community?

LGBTQ Health Centers are organizations or clinical sites focused on meeting the unique needs of the LGBTQ community. There are fewer than 300 LGBTQ health centers in the U.S., the majority of which provide wellness programs, HIV/STI services and mental health counseling.7

Services Provided by LGBTQ Health Centers

State Of Survey participants who work at LGBTQ Health Centers are most likely to offer HIV prevention, STI screening, and counseling.

However, responses also pointed towards gaps in sexual healthcare, with under half providing gender affirming care and viral hepatitis services. These gaps are concerning because they are likely even wider in primary/general healthcare settings. LGBTQ people need comprehensive and specialized services to meet their needs, and LGBTQ Health Centers are best equipped to do this while protecting the rights and dignity of their clients.


Cultural Humility Starts with Organization Policy and Culture

Creating an inclusive environment that supports LGBTQ patients seeking primary care is essential for fostering a diverse and empathetic healthcare workforce.

Identity Affirming Practices

Less than half of respondents (40%) indicated providing services primarily to the LGBTQ community. However the reach of those organizations is wide as the majority (75%) have a relationship with external LGBTQ supportive service agencies.

The majority of organizations are engaging in identity affirming practices, with over 85% reporting the presence of gender identity, sex at birth, and sexual orientation fields on their patient forms. However, only 70% have forms that include pronouns or preferred name fields, and less than two-thirds have gender neutral bathrooms on-site.

Consistent with the Inaugural State of LGBTQ Health Survey (2022), respondents most frequently estimated that fear of stigma or discrimination, distrust in health systems or professionals, and mental health issues are the most significant barriers facing LGBTQ clients seeking care.

Respondents called for hiring culturally sensitive and accommodating staff, offering LGBTQ specific training, and working with experienced providers or peer mentoring programs as strategies to facilitate better LGBTQ-centered care. These suggestions are crucial, as less than half of respondents report providing LGBTQ-specific services and culturally tailored interventions, and only 57% felt very confident in using inclusive, affirming, and culturally sensitive terminology when speaking with LGBTQ clients.


These findings reflect national trends surrounding LGBTQ healthcare and the reported lack of LGBTQ health education in medical schools.8

In the 2015 United States Trans Survey, 33% of respondents who had seen a primary care provider reported negative experiences in the healthcare environment related to their transgender identity, and almost one quarter of all respondents said they refrained from seeking medical care at least once in the preceding year due to fear of being mistreated for their gender identity.9 Discrimination-related trauma can have a significant negative impact on health outcomes. Accordingly, healthcare employers, medical schools, medical education companies/organizations, and health departments need to prioritize LGBTQ healthcare training for the workforce in order to have a material impact on LGBTQ community well-being.

Providers Indicate Lack of Culturally Sensitive Staff and LGBTQ-Specific Training

More than half of respondents identified LGBTQ-specific training as one of the most significant facilitators to providing services to LGBTQ clients and patients.

When asked to prioritize training topics, respondents most frequently highlighted stigma and discrimination, creating a welcoming environment for LGBTQ clients, and LGBTQ health disparities. Clinical providers and nurses in particular reported caring for LGBTQ youth and suicide prevention as the most needed training topics for LGBTQ care.


The lack of comprehensive training for healthcare providers in addressing the unique needs of the LGBTQ community is a pressing concern that requires immediate attention. Research shows that many sexual health providers still receive no training on and feel comfortable providing care to their transgender patients.9 Crucially, even where training does exist, providers report its inadequacy; a 2018 study examining variations in LGBTQ health across medical disciplines found that less than 50% of participating students felt their formal training prepared them for treating LGBTQ patients.10 This is a remarkable gap given the extent of health disparities facing LGBTQ people, and transgender people in particular.

Mpox Vaccine Outreach Needed at Wider Range of Healthcare Sites, Including Pharmacies and Private Practice

In May, 2022, an outbreak of Mpox virus (MPV) (formerly called monkeypox) began in the U.S., primarily impacting gay and bisexual men.11

Promisingly, over half of respondents indicated their organization offers the Mpox vaccine. However, the majority of pharmacies (86%) and private practices (67%) do not offer the vaccine, pointing towards potential sites for intervention in efforts to close remaining gaps. Participants surmised the top reason for vaccine hesitancy/refusal is low assumption of risk, and 60% expressed concern that clients and patients could still contact Mpox.


Mpox is highly contagious and passes through contact with its characteristic skin lesions.12 It is likely that people living with HIV — who account for 48% of overall Mpox cases globally — experience worse Mpox outcomes due to weakened immune response.13 It is therefore recommended that PLWH receive a vaccine to lower the risk of infection.14

Gender Affirming Care Remains Challenging to Provide in the Current Healthcare Landscape

It is evident from survey findings that providers consider education and training to be the most important factor in their ability to provide gender-affirming care.

This is critical because providers who are uncertain about their capacity to perform gender-affirming interventions are less likely to engage at all, leaving their transgender and gender non-conforming (GNC) patients without recourse. In the absence of adequate training, however, many respondents report seeking collaboration with experienced providers or peer mentoring programs. These types of referral relationships could be a useful avenue for organization leaders hoping to serve more transgender and GNC clients with limited internal capacity.

When asked about access barriers, respondents pinpointed specific challenges encountered by patients seeking gender-affirming care. Fear of stigma or discrimination was recognized as the top barrier (64.3%), followed by distrust in the healthcare system and professionals (46.0%) and issues with cost or insurance (41.3%).

Participant responses echo well-established barriers to gender affirming care in the U.S.15 General lack of engagement with healthcare services is one major issue, with studies showing that as much as 20-30% of transgender individuals lack primary care providers.16 Additionally, while culturally competent and gender-affirming primary care are considered best practices, gaps in gender-related healthcare training remain persistent and are partially responsible for low service access rates among transgender and GNC clients/patients.16, 17 The unique needs of transgender and GNC clients/patients necessitate a comprehensive approach involving, not only specialty providers, but primary care physicians and other generalists who are currently struggling to access adequate related training.

Advocacy Issues

When asked to rank the advocacy and policy issues they are most concerned about in 2023, respondents prioritized LGBTQ equality issues and nondiscrimination protections, followed by gender affirming care protections and affordable housing.

Despite advancements in recent years, 29 states still do not have non-discrimination protections for LGBTQ individuals.18 Since 2020, Over 100 bills attacking transgender people have been introduced in state legislatures.19 Although the American Medical Association opposes bans on gender affirming care and deems medical and surgical treatment for gender dysphoria as necessary,20 19 states have enacted laws aimed at prohibiting access to best-practice gender affirming care.21

Additionally, barriers to housing access continue to pose a dire threat to the well-being of LGBTQ Americans. Currently, there is no state where a person working full-time at local minimum wage can afford a 2-bedroom rental, an economic reality that has led to an estimated shortage of 7 million affordable homes for low-income workers.22 Over one in five LGBTQ adults are living in poverty and LGBTQ youth are 2.2 times more likely to experience homelessness than their non-LGBTQ peers.23 Developing new strategies for housing dislocated LGBTQ individuals is crucial to ensuring their access to quality health care.

LGBTQ Health Criminalization

More than half of U.S. states have introduced, advanced, or passed healthcare bills targeting LGBTQ rights.

Despite the prevalence of healthcare criminalization targeting LGBTQ people, less than half of respondents reported being aware of anti-LGBTQ healthcare bills in their state or region.

However, the majority of respondents who were aware, believe that these policies impact the health of their clients or patients. Many have observed how the recent escalation of anti-trans healthcare legislation is having a negative impact on the mental health of transgender and/or GNC clients or patients. Some even indicated that local legislation has prevented them from providing healthcare to LGBTQ clients or patients.

Legislation recently introduced in 22 states calling for complete bans on gender-affirming care opposes the guidelines generated by American Academy of Pediatrics and the Endocrine Society.24 Transgender and GNC youth experience elevated rates of poor mental health outcomes compared to their counterparts, and research shows that both providers and guardians believe anti-LGBTQ laws will exacerbate these issues.24, 25

Access to gender-affirming care is significantly associated with a decrease in suicidality and other adverse mental health outcomes among transgender and nonbinary adults and youth.26 The 2023 National Survey on the Mental Health of LGBTQ Young People, conducted by The Trevor Project, found that close to one in three LGBTQ youth reported frequent poor mental health due to anti-LGBTQ legislation.5

Conclusion

The state of LGBTQ Health Care is both promising and challenging. The report underscores the critical need for ongoing training and support to empower LGBTQ providers in their battle against stigma and the pursuit of health equity. While strides have been made, significant barriers, including distrust, mental health struggles, and financial constraints, continue to impede access to care for LGBTQ individuals.

However, with a resolute focus on cultural competency and collaboration, the healthcare community can take meaningful steps toward creating more welcoming and inclusive environments. As we step into 2024, advocacy efforts stand tall, championing LGBTQ equality, robust gender-affirming care, and accessible housing. It is imperative that we recognize the impact of anti-LGBTQ legislation and work collectively to raise awareness and dismantle these barriers to equitable healthcare. This report serves as both a reflection of the current state of LGBTQ healthcare and a call to action, emphasizing the importance of ongoing commitment to progress and inclusivity in the pursuit of a healthier and more equitable future for all.

The National Coalition for LGBTQ Health

The National Coalition for LGBTQ Health was formed with the aim of eliminating health disparities across issues of sexual orientation, gender identity and presentation, gender, race and ethnicity, education or income, disability, nationality, geographic location and age, and represents the rich diversity of the LGBTQ communities nationwide and reaches across gender/gender identity, race/ethnicity, disability, education, income, age, and geography. Coalition membership includes the leading LGBTQ health centers and local and state health departments—as well as leaders in LGBTQ policy across the US. The Coalition’s individual membership also includes leading researchers and health care providers who work in HIV/AIDS, biomedical prevention, health disparities in minority communities, mental health in the LGBTQ communities, and other vital areas of medicine and public health. The Coalition draws its vision and its focus of mission from the breadth of work, experiences, and perspectives lent by its members.

Appendix: Research Strategy

Survey Methodology

Survey Development

The survey consisted of a mix of 197 open- and closed-ended survey questions. Internal and external advisory groups reviewed the survey to ensure the questions encompassed salient issues facing LGBTQ people as described in the literature.

Participant Recruitment

The survey was developed using a status-neutral framework and with an emphasis on systemic and structural barriers, so as to capture a full picture of LGBTQ healthcare landscape ranging from advocacy and PrEP programs, to primary, HIV, and behavioral healthcare. This survey was conducted on behalf of the National Coalition for LGBTQ Health, a partnership of providers and organizations committed to improving the health and qualities-of-life of LGBTQ individuals through federal and local advocacy, education, and research.

The survey was administered online via Research Electronic Data Capture (REDCap) from May 20, 2023 – June 26, 2023.27, 28 Respondents were recruited through the HealthHIV constituent relationship management (CRM) database, SalsaLabs, which includes approximately 80,000 persons who reflect the diverse cross-section of LGBTQ people and other populations disproportionately impacted by HIV in the U.S. There was wide representation of racial and ethnic minorities and sexual and gender minorities, across geographic location, educational status, and income levels. No incentive was provided for participation.

Data Analysis

Basic descriptive statistics were calculated in REDCap. Additional univariate, bivariate, and multivariate statistical analyses were calculated using RStudio 4.2.1 statistical software.29 Thematic content analysis was used to explore qualitative data and identify themes that captured respondent experiences.

Survey Participants

Participants were all members of the healthcare workforce with direct experience providing or supporting care to the LGBTQ community. A total of 1023 providers participated in the survey, responding to questions on training needs, HIV/STI prevention, workforce burnout, gender-affirming care, LGBTQ health policy, and more.

Respondent Demographics

Survey participants were predominantly white, cisgender women between the ages of 35 and 54. However, there was also strong representation of Black/African American respondents and older people aged 55-64. 18% identified as Latino/a/x.

Participants hailed from a wide range of U.S. states and geographies, with representation from 48 states and 2 territories.

Participant demographics reflect those of healthcare professionals in the U.S., as demonstrated by HRSA’s 2017 report showing that healthcare professionals are primarily White (64.4%), with only 16% identifying as Hispanic and 12% identifying as Black or African American, nationally.30

Professional Backgrounds

Participation reflects a wide distribution of provider types and professional and geographic settings.

Just over two-thirds of respondents fill non-clinical professional roles while the remaining third identify as clinical providers. Among clinical respondents, 40% are able to prescribe medications. The most common non-clinical participant roles include administrators, case managers, and community health workers; the most common clinical roles include nurses (RNs, NPs, LPNs, and nurse managers), physicians, and clinical social workers.

Organizational Affiliations

The most represented participant professional settings were non-profit organizations, Federally Qualified Health Centers (FQHCs), AIDS Service Organizations (ASOs), and health department/public health clinics. Organizations were primarily located in urban areas, followed by rural and suburban.

Notes

  1. Centers for Disease Control and Prevention. About LGBT Health | Lesbian, Gay, Bisexual, and Transgender Health | CDC. Lesbian, Gay, Bisexual, and Transgender Health. Published October 14, 2022. Accessed September 20, 2023. https://www.cdc.gov/lgbthealth/about.htm
  2. Zeeman L, Sherriff N, Browne K, et al. A review of lesbian, gay, bisexual, trans and intersex (LGBTI) health and healthcare inequalities. Eur J Public Health. 2019;29(5):974-980. doi:10.1093/eurpub/cky226
  3. Division of Diversity and Health Equity APA. Mental Health Disparities: LGBTQ. Published online 2017. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-LGBTQ.pdf
  4. Scheim AI, Baker KE, Restar AJ, Sell RL. Health and Health Care Among Transgender Adults in the United States. Annu Rev Public Health. 2022;43:503-523. doi:10.1146/annurev-publhealth-052620-100313
  5. 2023 U.S. National Survey on the Mental Health of LGBTQ Young People. The Trevor Project Accessed September 15, 2023. https://www.thetrevorproject.org/
  6. Maird B, Khattra N. How can LGBTQ cultural competency be increased in a health care setting? Published online 2023. Accessed September 20, 2023. https://dc.arcabc.ca/islandora/object/dc:58077
  7. Sandy E. James, Jody L. Herman, Susan Rankin, Mara Keisling, Lisa Mottet, Ma’ayan Anafi. Executive Summary of the Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality; 2016. http://www.USTransSurvey.org
  8. Gentile D, Boselli D, MacNeill E. Clinician’s Experience and Self-Perceived Knowledge and Attitudes toward LGBTQ + Health Topics. Teach Learn Med. 2021;33(3):292-303. doi:10.1080/10401334.2020.1852087
  9. Stenzel AE, Moysich KB, Ferrando CA, Starbuck KD. Clinical needs for transgender men in the gynecologic oncology setting. Gynecol Oncol. 2020;159(3):899-905. doi:10.1016/j.ygyno.2020.09.038
  10. Greene MZ, France K, Kreider EF, et al. Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health. PLOS ONE. 2018;13(9):e0204104. doi:10.1371/journal.pone.0204104
  11. World Health Organization. Mpox (monkeypox). Fact Sheets: Mpox (monkeypox). Published April 18, 2023. Accessed September 18, 2023. https://www.who.int/news-room/fact-sheets/detail/monkeypox
  12. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP). How It Spreads | Mpox | Poxvirus | CDC. Mpox – How It Spreads. Published August 31, 2023. Accessed September 18, 2023. https://www.cdc.gov/poxvirus/mpox/if-sick/transmission.html
  13. Saldana CS, Kelley CF, Aldred BM, Cantos VD. Mpox and HIV: a Narrative Review. Curr HIV/AIDS Rep. Published online May 13, 2023:1-9. doi:10.1007/s11904-023-00661-1
  14. CDC, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP). Mpox Vaccine Recommendations. Centers for Disease Control and Prevention. Published August 21, 2023. Accessed September 18, 2023. https://www.cdc.gov/poxvirus/mpox/vaccines/vaccine-recommendations.html
  15. Warner DM, Mehta AH. Identifying and Addressing Barriers to Transgender Healthcare: Where We Are and What We Need to Do About It. J Gen Intern Med. 2021;36(11):3559-3561. doi:10.1007/s11606-021-07001-2
  16. Korpaisarn S, Safer JD. Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons. Rev Endocr Metab Disord. 2018;19(3):271-275. doi:10.1007/s11154-018-9452-5
  17. Poteat T, Davis AM, Gonzalez A. Standards of Care for Transgender and Gender Diverse People. JAMA. 2023;329(21):1872-1874. doi:10.1001/jama.2023.8121
  18. The White House. FACT SHEET: The Equality Act Will Provide Long Overdue Civil Rights Protections for Millions of Americans. The White House. Published June 25, 2021. Accessed September 20, 2023. https://www.whitehouse.gov/briefing-room/statements-releases/2021/06/25/fact-sheet-the-equality-act-will-provide-long-overdue-civil-rights-protections-for-millions-of-americans/
  19. American Civil Liberties Union. LGBTQ Rights. ACLU. Accessed September 15, 2023. https://www.aclu.org/issues/lgbtq-rights
  20. American Medical Association. AMA reinforces opposition to restrictions on transgender medical care. American Medical Association. Published June 15, 2021. Accessed September 20, 2023. https://www.ama-assn.org/press-center/press-releases/ama-reinforces-opposition-restrictions-transgender-medical-care
  21. Movement Advancement Project. Health Care / Bans on Best Practice Medical Care for Transgender Youth. MAP. Published September 18, 2023. Accessed September 20, 2023. https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans
  22. National Low Income Housing Coalition. 2023 Out of Reach: The High Cost of Housing; 2023. Accessed September 20, 2023. https://nlihc.org/oor/about
  23. Adam P. Romero, Shoshana K. Goldberg, Luis A. Vasquez. LGBT People and Housing Affordability, Discrimination, and Homelessness. The Williams Institute; 2020. Accessed September 20, 2023. https://williamsinstitute.law.ucla.edu/publications/lgbt-housing-instability/
  24. Hughes LD, Kidd KM, Gamarel KE, Operario D, Dowshen N. “These Laws Will Be Devastating”: Provider Perspectives on Legislation Banning Gender-Affirming Care for Transgender Adolescents. J Adolesc Health. 2021;69(6):976-982. doi:10.1016/j.jadohealth.2021.08.020
  25. Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics. 2020;145(2):e20191725. doi:10.1542/peds.2019-1725
  26. Green DC, Parra LA, Goldbach JT. Access to health services among sexual minority people in the United States. Health Soc Care Community. 2022;30(6):e4770-e4781. doi:10.1111/hsc.13883
  27. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010
  28. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi:10.1016/j.jbi.2019.103208
  29. RStudio Team. RStudio: Integrated Development for R. Published online 2020. Accessed September 6, 2023. https://www.rstudio.com/
  30. HRSA Health Workforce. Sex, Race, and Ethnic Diversity of U.S. Health Occupations (2011-2015). U.S. Department of Health and Human Services; 2017. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/diversity-us-health-occupations.pdf

HealthHIV Research and Evaluation

State of Aging With HIV

State of ASOs & CBOs

State of Harm Reduction

State of HCV Care

State of HIV Care

State of LGBTQ Health

HealthHIV Research and Evaluation conducts regular national surveys to better inform ongoing advocacy, education, research, and training activities. These “State Of” surveys provide unique insight into patient and provider issues in order to optimize primary and support services for diverse communities. The regular reports offer the ability to study multi-year trend analyses illustrating changes, challenges, and opportunities to address the needs of providers and patients. HealthHIV, HealthHCV and the National Coalition for LGBTQ Health conduct State of surveys addressing HIV care, HCV care, LGBTQ healthcare, and aging with HIV.

HealthHIV.org/StateOf

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HealthHIV is a national non-profit working with healthcare organizations, communities, and providers to advance effective HIV and HCV prevention, care, and support through education and training, technical assistance and capacity building, advocacy, communications, and health services research and evaluation.

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