In 2022, the proportion of U.S. adults identifying as lesbian, gay, bisexual, and transgender (LGBT) was 7.2%, a number that appears to be leveling off following several years of increase (Jones, 2023). However, the share of the U.S. population that identifies as LGBT is likely underestimated in survey data given the social challenges associated with disclosing sexual orientation and gender identity (Coffman et al., 2017). Among adults identifying as LGBT, there are large differences in orientation between older and younger generations, with fully 66% of LGBT adults in Generation Z (those born between 1997 and 2004) reporting bisexual identity (Jones, 2023). LGBT individuals experience health concerns similar to the general population but face specific policy barriers and socio-structural challenges in accessing healthcare services, including explicit and implicit preferences for heterosexual patients on the part of healthcare providers (Sabin et al., 2015). Men and women in same-sex relationships have significantly lower rates of health insurance coverage and higher rates of unmet medical needs compared to those in different-sex relationships (Buchmueller & Carpenter, 2010; Dilley et al., 2010). While passage of the Affordable Care Act in 2010 has led to improved access for some sexual minority patients, disparities in health insurance coverage persist (Skopec & Long, 2015).
Heteronormative assumptions, such as the use of cis-gendered and heterosexual relationship terms on medical intake forms, and extra documentation requirements to ensure partner access and participation in care, are reported by this patient population (Quinn et al., 2015). LGBTQ (Queer) patients report experiencing stigma and encountering providers with insufficient knowledge of specific LGBTQ health needs, a finding that is consistent with shortfalls in culturally-competent LGBTQ care (Nowaskie & Sowinski, 2019). LGBTQ patients report discomfort while accessing care; delays to, and avoidance of, care; and concealment of their LGBTQ identity in healthcare settings (Dahlhamer et al., 2016; Rossman et al., 2017; Smith & Turell, 2017). These problems lead to unmet healthcare needs and poorer health outcomes for LGBT individuals (Fredriksen-Goldsen et al., 2013; Bränström, 2016). For example, lesbian women were less likely to receive regular Pap screening for cervical cancer and be offered a clinical breast exam and LGBT individuals are more likely to become disabled at a younger age than heterosexual individuals (Diamant et al., 2000; Fredriksen-Goldsen et al., 2012). Additionally, LGBT individuals are at elevated risk of smoking, substance use disorders, and psychological distress (Flentje et al., 2015; Operario et al., 2015).
Primary care physicians are an important source of preventative care and screening recommendations (Starfield et al., 2005). Since LGBTQ-affirming primary care has been identified as an important factor in increasing access and decreasing disparities for LGBTQ individuals, guidelines for primary care have been developed to increase culturally-affirming care for LGBT people (McNair & Hegarty, 2010; Furness et al., 2020). At the same time, negative implicit and explicit biases towards gay and lesbian patients among healthcare providers are pervasive, and gay men and bisexual women report greater difficulty in finding a provider than their heterosexual counterparts (Buchmueller & Carpenter, 2010).
This paper employs experimental methods to directly assess the extent to which attitudes in the primary care system affect access for lesbian and gay patients. Access is defined across several dimensions as (1) the offer of an appointment with a requested or substitute provider; (2) the wait time to an appointment; (3) whether or not a practice accepts a patient’s insurance type and (4) the duration of any offered appointment. Wait times are an important indicator of access since long wait times increase the probability that an appointment will not be kept (Peterson et al. 2015) and may be interpreted by patients as a “soft” rejection leading to abandonment of attempts to seek medical care. Long wait times are a source of dissatisfaction for patients with women patients experiencing more dissatisfaction compared to men, an effect attributed to greater risk aversion on the part of women (Liu, 2018). Insurance type serves as a proxy for socio-economic status and age because Medicaid patients and those who self-insure are typically low income and Medicare is a U.S. federal government program for those over the age 65. Appointment duration is potentially an important measure of access and has been linked to physician characteristics such as gender, although its role in influencing patient outcomes is unclear (Stevens et al., 2017).
In order to explore the role of intersectionality between several identities, we examine whether physicians’ willingness to offer new patient appointments to lesbian and gay patients differs by the patient’s race/ethnicity, sex, and insurance type. Black and Hispanic patients, without regard to sexual minority status, are disadvantaged in access to primary care (Sharma et al., 2015). At the theoretical level, the role that intersectionality plays in determining relative advantages and disadvantages is ambiguous (Purdie-Vaughns & Eibach, 2008), making this an important topic of empirical inquiry in healthcare and other settings.
Research that examines the ways in which physician attitudes towards LGBT individuals influences access to primary care is limited. Also unknown is the way in which race/ethnicity, sex, age and social class intersect with lesbian and gay identities in influencing access to primary care. Self-reported attitudes towards lesbian and gay individuals have greatly improved in the last decade in the US and in many other countries (Poushter & Kent, 2020) which may mean that even relatively recent research in this area does not reflect the current experience of lesbian and gay individuals in healthcare and other settings. Quantitative evidence of the type provided by a field experiment such as this is important for guiding policy in the area of improving access and reducing disparities for LGBTQ patients.