WVU research finds LGBTQ people face barriers to health care, especially in rural areas

During Pride Month, it’s easy to find rainbow-colored health and wellness products—from bandages, to mouthwash, to fitness trackers—in stores or online. But actual health care that meets the needs of members of the LGBTQ community can be harder to get.

A new qualitative study by Zachary Ramsey—a doctoral candidate in the West Virginia University School of Public Health—suggests sexual and gender minorities may face unique barriers to health care, most particularly in rural areas.

His findings appear in the Journal of Gay and Lesbian Social Services.

“Research into sexual and gender minorities is growing quickly, but mainly in large urban centers,” he said. “There are a lot of differences between urban and rural populations for a general population, so it stands to reason that there would be a lot of differences between urban and rural LGBTQ individuals. Without more studies of LGBTQ rural individuals specifically, these differences will not be known, and policies and rural LGBTQ Center programming can only use an urban population for guidance.”

Ramsey’s study is the first-of-its-kind to explore researchers’ perspectives on the health needs of LGBTQ individuals.

He interviewed five researchers who study the LGBTQ population. The researchers were faculty members at universities in California, Michigan, Pennsylvania and Texas.

He also spoke with five physicians who practiced in the Appalachian regions of Pennsylvania, Virginia and West Virginia.

“Interviewing researchers and providers allows for an examination of the population with a much smaller sample size because each researcher and provider can speak to multiple LGBTQ individuals, while an LGBTQ individual that is not a provider or researcher can only speak to their experience as an individual,” he said.

Each interview comprised open-ended questions about the priority health needs of sexual and gender minorities.

For example, Ramsey asked every participant what they believed were the most pressing health issues that the LGBTQ community faces. 

Four issues dominated the participants’ answers: 

• The interconnectedness of physical, mental and social health.
• The harm that discrimination causes.
• Heteronormativity or the belief that a heterosexual and cisgender identity is the only “normal” one. 
• Health care system barriers, such as insurance plans that do not cover necessary treatments and health care providers who have not been trained to handle LGBTQ concerns.

These issues may seem abstract, but their implications for LGBTQ individuals are anything but.

For instance, “having a heteronormative worldview puts a lot of pressure on the patient to disclose information when the provider is not asking the correct things or is making assumptions,” Ramsey said.

Imagine a 45-year-old patient who was born female, identifies as male, but has not undergone gender-affirmation surgery. Mammograms could reduce his risk of death from breast cancer, but he may not get them if his doctor assumes he is a cisgender male and underestimates his breast cancer risk.   

Now imagine that the patient is a cisgender male. He has sexual partners of multiple genders but is reticent about it because he lives in a small, rural, socially conservative town where stigma lingers around same-sex experiences. Breast cancer screenings may not benefit him, but if he can’t speak candidly to his doctor, he may miss out on screenings for cancers related to the human papillomavirus—cancers that are more common in men who have sex with men.

“A provider who is open and does not assume aspects of their patient can show the patient that they are receptive to expansive sexualities and genders beyond heterosexual and cisgender,” Ramsey said. “This takes the pressure off of the patient and relieves the stress of dealing with the fear that the provider will not be receptive to their sexuality or gender.”

Real-life examples abounded in the interviews Ramsey and his colleagues conducted, transcribed and analyzed.

One participant mentioned that if sexual and gender minorities grow up in families that don’t accept them, the rejection can cause mental health problems that persist into adulthood. 

Other participants brought up that violence—and the resulting post-traumatic stress—can be of critical concern for LGBTQ individuals.

Still others noted that sexual and gender minorities have higher rates of suicide and suicidal ideation and that medical school training often excludes the trans community from its curriculum. 

And they noted that insurance companies might decline to pay for treatments if, at first glance, they don’t seem gender appropriate. 

Rurality can present its own difficulties. Participants pointed out that neither LGBTQ social networks nor doctors familiar with LGBTQ concerns are likely to proliferate in rural areas. The resulting isolation can sabotage the health of sexual and gender minorities.

“Bringing more providers into rural areas would be a great benefit, not only to the individuals who have to drive a few hours to see an endocrinologist for hormones, but to the general population that can sometimes struggle to find appropriate services,” Ramsey said.

Consider this: 20% of Americans live in rural areas, but according to the Association of American Medical Colleges, only 11% of physicians practice there. Three out of five federally designated health professional shortage areas are in rural regions. 

In addition, trainings that prepare health care providers to talk with LGBTQ patients could be advantageous. That is particularly true in rural areas, where providers may have relatively little experience with patients who are “out.”

“Breaking down that stigma and removing the pressure from the patients to inform and educate their provider can greatly increase the access by simply making the providers who are around approachable,” Ramsey said.

“Issues such as social and geographic isolation, provider and medical system shortages, and transportation barriers are especially pronounced in rural areas,” said Danielle Davidov, an associate professor in the Department of Social and Behavioral Sciences and part of the research team. “These disparities in access to health and supportive services, coupled with risks of discrimination and stigma, may place LGBTQ patients in rural locations at a greater disadvantage when it comes to finding quality healthcare.”