Health Care Discrimination and Care Avoidance Due to Patient-Clinician Identity Discordance Among Sexual and Gender Minority Adults

Michael Liu; Vishal R. Patel; Sahil Sandhu; Sari Reisner; Alex S. Keuroghlian

doi:10.1370/afm.3130

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Figure 1.
Health care discrimination and care avoidance due to patient-clinician identity discordance by sexual orientation and gender identity.
Note: Adjusted prevalence rates were derived from multivariable robust Poisson regression models that included sexual orientation (Panel A) or gender identity (Panel B), health care discrimination score, an interaction term between sexual orientation × health care discrimination score or an interaction term between gender identity × health care discrimination score, age, sex assigned at birth, race and ethnicity, annual household income, educational attainment, insurance status, relationship status, birthplace, and survey year. Health care discrimination scores were modeled using natural cubic splines with 3 degrees of freedom. Shaded regions represent 95% CIs.
^a Participants delaying or forgoing health care because clinician was of a different background.
^b Health care discrimination was assessed using the 7-item Discrimination in Medical Settings scale, which measures exposure to discrimination while receiving health care (eg, provided poorer service or treated with less courtesy and respect). All items were scored on a 5-point Likert scale (from 1 = never to 5 = always). The final score was calculated by summing responses across all items (resulting in total scores between 7 and 35) and calculating a mean score by dividing this sum by the number of answered questions (resulting in mean scores between 1 and 5).

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Table 1.

Characteristics of All of Us Participants by Sexual Orientation and Gender Identity

	No. (%)
	Heterosexual Adults	Sexual Minority Adults	P Value^{^a}	Cisgender Adults	Gender Minority Adults	P Value^{^a}
Sample size, No.	87,431	9,699		97,032	1,277
Health care discrimination score, median (IQR)	1.29 (0.86)	1.57 (1.00)	<0.001	1.43 (0.86)	2.00 (1.14)	<0.001
Age, median (IQR)	61 (23)	44 (29)	<0.001	60 (24)	33 (19)	<0.001
Female sex	57,131 (65.3)	6,005 (61.9)	<0.001	63,039 (65.0)	915 (71.6)	<0.001
Race and ethnicity
Asian	2,317 (2.7)	256 (2.7)	<0.001	2,589 (2.7)	44 (3.5)
Black	6,188 (7.2)	510 (5.3)		6,808 (7.1)	47 (3.7)
Hispanic	6,808 (7.9)	888 (9.2)		7,853 (8.2)	109 (8.6)
Other^{^b}	2,339 (2.7)	435 (4.5)		2,775 (2.9)	71 (5.6)
White	68,505 (79.5)	7,527 (78.3)		75,613 (79.1)	992 (78.5)
Annual household income, $
<25,000	9,459 (12.0)	1,826 (19.9)	<0.001	11,282 (12.8)	321 (27.2)	<0.001
25,000-50,000	12,915 (16.3)	1,873 (20.4)		14,680 (16.7)	282 (23.9)
50,00-100,000	24,146 (30.5)	2,594 (28.3)		26,682 (30.3)	301 (25.5)
100,000-150,000	15,154 (19.2)	1,378 (15.0)		16,475 (18.7)	155 (13.1)
≥150,000	17,407 (22.0)	1,489 (16.3)		18,827 (21.4)	123 (10.4)
Educational attainment
High school or lower	8,839 (10.2)	879 (9.1)	<0.001	9,873 (10.3)	155 (12.2)	<0.001
Some college	20,110 (23.2)	2,374 (24.6)		22,422 (23.3)	352 (27.8)
Bachelor’s degree or higher	57,721 (66.6)	6,384 (66.2)		63,882 (66.4)	758 (59.9)
Uninsured	1,930 (2.2)	256 (2.7)	0.007	2,213 (2.3)	46 (3.7)	0.002
Relationship status
Married or living with partner	56,621 (65.3)	4,692 (48.8)	<0.001	61,178 (63.6)	550 (43.6)	<0.001
Never married	12,077 (13.9)	3,600 (37.5)		15,556 (16.2)	552 (43.8)
Widowed, separated, or divorced	18,026 (20.8)	1,313 (13.7)		19,453 (20.2)	159 (12.6)
Non-US–born	8,326 (9.6)	706 (7.3)	<0.001	9,222 (9.6)	74 (5.8)	<0.001

IQR = interquartile range.
↵a Characteristics were compared across sexual orientation and gender identity groups using χ² tests and Mann-Whitney U tests.
↵b Individuals who identified as “Middle Eastern or North African,” “Native Hawaiian or Other Pacific Islander,” “More Than One Population,” or “None of These.”

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Table 2.

Care Avoidance Due to Patient-Clinician Identity Discordance Among Sexual and Gender Minority Adults

Group	Care Avoidance Due to Patient-Clinician Identity Discordance
Group	No. (%)	Adjusted Rate Ratio (95% CI)	P Value
Sexual orientation
Heterosexual adults (n = 87,431)	8,192 (9.4)	[Ref]	[Ref]
Sexual minority adults (n = 9,699)	1,944 (20.0)	1.58 (1.49-1.67)	<0.001
Gay adults (n = 2,673)	394 (14.7)	1.79 (1.60-2.01)	<0.001
Lesbian adults (n = 1,497)	248 (16.6)	1.47 (1.28-1.68)	<0.001
Bisexual adults (n = 3,973)	865 (21.8)	1.43 (1.32-1.55)	<0.001
Gender identity
Cisgender adults (n = 97,032)	9,968 (10.3)	[Ref]	[Ref]
Gender minority adults (n = 1,277)	438 (34.3)	2.00 (1.79-2.21)	<0.001
Transgender adults (n = 417)	131 (31.4)	2.03 (1.67-2.43)	<0.001
Non-binary adults (n = 626)	206 (32.9)	1.79 (1.54-2.07)	<0.001

Note: Adjusted rate ratios are from robust Poisson regression models adjusting for age, sex assigned at birth, race and ethnicity, annual household income, educational attainment, insurance status, relationship status, birthplace, and survey year.

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SUPPLEMENTAL MATERIALS IN PDF FILE BELOW

Supplemental Figure. Participant Flowchart

Supplemental Table 1. Definition of Sexual and Gender Minorities in the All of Us Research Program

Supplemental Table 2. Detailed Description of the Care Avoidance Due to Patient-Clinician Identity Discordance and Healthcare Discrimination Questions

329-SupplementalFigureTable1Table2.pdf -
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PLAIN-LANGUAGE ARTICLE SUMMARY

Research Brief

Sexual and Gender Minority Adults Avoid Necessary Care Due to Identity Discordance with Clinicians and Experiences of Discrimination

Background and Goal: Identity discordance between patients and clinicians is associated with worse self-rated patient experience and less receipt of necessary care. Most prior studies have focused on racial discordance. However, whether these phenomena also apply to sexual and gender minority adults is currently unknown. This study evaluated how prevalent avoidance due to patient-clinician identity discordance is and its potential association with health care discrimination among sexual and gender minority adults.

Study Approach: A cross-sectional analysis was conducted of the National Institutes of Health’s All of Us Research Program. Data were collected from adults aged 18 years or older enrolled between May 2018 and July 2022. Sexual minority, heterosexual, gender minority, and cisgender adults were identified based on responses to interview questions.

Results: After adjusting for sociodemographic characteristics, sexual minority adults were significantly more likely than heterosexual adults to report care avoidance on the basis of patient-clinician identity discordance. Gender minority adults were also more likely to report care avoidance in comparison to cisgender adults. Additionally, median health care discrimination scores were higher among sexual minority and gender minority adults relative to heterosexual and cisgender adults. Among sexual and gender minority adults, higher levels of health care discrimination were significantly associated with a higher prevalence of care avoidance.

Why It Matters:

These findings are consistent with emerging qualitative research showing that sexual and gender minority patients prefer clinicians who share similar sexual orientations and/or gender identities. Patient preferences are likely due to a desire for more affirming care and expertise specific to sexual and gender minorities, in addition to perceptions of safety, comfort, and solidarity.