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RESEARCH AND PRACTICE |
At the time of the study, Julia E. Heck was a doctoral student in the Department of Epidemiology and a fellow with the Institute for Social and Economic Research and Policy, Columbia University, New York City. Randall L. Sell is with the Department of Sociomedical Sciences, Columbia University. Sherri Sheinfeld Gorin is with the Departments of Epidemiology and Sociomedical Sciences, Columbia University, and the Department of Health and Behavior Studies, Teacher’s College, Columbia University.
Correspondence: Requests for reprints should be sent to Sherri Sheinfeld Gorin, PhD, Department of Health and Behavior Studies, 525 W 120th St, Box 239, Thorndike 954, New York, NY 10027 (e-mail: ssg19{at}columbia.edu).
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ABSTRACT |
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Objectives. We used data from the National Health Interview Survey to compare health care access among individuals involved in same-sex versus opposite-sex relationships.
Methods. We conducted descriptive and logistic regression analyses from pooled data on 614 individuals in same-sex relationships and 93418 individuals in opposite-sex relationships.
Results. Women in same-sex relationships (adjusted odds ratio [OR]=0.60; 95% confidence interval [CI]=0.39, 0.92) were significantly less likely than women in opposite-sex relationships to have health insurance coverage, to have seen a medical provider in the previous 12 months (OR=0.66; 95% CI=0.46, 0.95), and to have a usual source of health care (OR=0.50; 95% CI=0.35, 0.71); they were more likely to have unmet medical needs as a result of cost issues (OR=1.85; 95% CI=1.16, 2.96). In contrast, health care access among men in same-sex relationships was equivalent to or greater than that among men in opposite-sex relationships.
Conclusions. In this study involving a nationwide probability sample, we found some important differences in access to health care between individuals in same-sex and opposite-sex relationships, particularly women.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Research on the GLB population has been limited by a lack of population-based data involving probability samples. Because information on sexual orientation is not collected in most national surveys, data on health care access among GLB individuals have often been limited to local surveys or health center–based convenience samples. Although this selection bias must be taken into account, the findings of these studies suggest reduced health care access in the GLB population relative to the overall US population. Notably, GLB individuals may use preventive care services at a reduced rate. Some studies suggest that lesbians may undergo mammography and Papanicolaou testing less frequently than other women.5–10 Also, there is evidence that gay men may use health services less frequently than their heterosexual counterparts.11,12
According to the Institute of Medicine, health insurance is the most important factor in US residents’ receipt of timely and appropriate health care.13 Studies focusing on health insurance coverage among men with HIV who have sex with men have revealed that these men have coverage rates lower than those of the general population.14–17 However, because of the association between HIV and poverty and seropositive individuals’ potentially greater access to Medicaid and other low-cost health programs, it is difficult to generalize these rates to all gay men.17–20
Results of regional and national surveys focusing on lesbian populations have varied in terms of the percentages of women reporting health insurance coverage, with rates ranging from 72% to 87%; health insurance coverage is usually shown to be less prevalent among lesbians and bisexual women than among heterosexual women.5,10,15,21–23 Reduced use of health care services is a concern among lesbians and bisexual women, given reports that rates of cigarette smoking and alcohol use are higher among GLB individuals than among other adult groups.5,24,25 These behavioral differences, in addition to lower screening rates, have led to some researchers postulating that lesbians may be at higher risk of certain cancers.26,27
Health care access among the GLB population has been an understudied area of public health. To our knowledge, no population-based national surveys have used random probability samples to measure health care access in this population. We examined health insurance coverage and other indicators of health care access among individuals involved in a same-sex relationship (SSR), hypothesizing that such individuals would be less likely than those living with an opposite-sex spouse or partner to have insurance coverage, to use health care services, and to have a regular source of care.
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METHODS |
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Sample Selection and Definition of Same-Sex Relationships
We included in our analyses adults 18 to 64 years of age who were living with a spouse or partner during the data collection period assessed here (1997–2003). Respondents’ self-reported sexual orientation was not ascertained. In the NHIS sampling design, an adult household reference person is selected within each survey household, and other household members’ gender and their relationship with the reference person are recorded. The procedure followed by interviewers is to ask the name of each person in the household and then ask of the household reference person, "What is [each person’s name]’s relationship to you?" Among others, possible responses are "spouse (husband/wife)" and "unmarried partner."
In this manner, individuals living with same-sex or opposite-sex spouses or partners were identified for the period under study. Although it is not known whether these relationships were monogamous, there were no respondents for whom more than one partner or spouse was identified. If one partner in a relationship was not identified as the household reference person (e.g., cases in which extended families with multiple adults lived together in a household), it was not possible to determine whether a couple was living in the household. As such, some same-sex and opposite-sex partnerships may have been excluded.
In every household, a sample adult was randomly selected to complete an in-depth interview. If either the reference person or his or her spouse or partner was selected as the sample adult, this individual was included in the analysis. The sample did not include more than one person from any given household. The final sample sizes for the present analyses were 614 individuals involved in an SSR and 93418 individuals involved in an opposite-sex relationship (OSR). (We use the terms "GLB" and "heterosexual" to describe the population as a whole and "SSR" and "OSR" to refer to the participants in the NHIS sample.)
Indicators of Interest
Our choices of explanatory variables were guided by the model formulated by Andersen, which suggests that patterns of health care use are influenced by predisposing, enabling, and need-related factors, as well as environmental conditions.29 The predisposing variables on which we focused included age, race, educational attainment, and a behavior-related factor, smoking status. Enabling factors included family income, employment status, and health insurance status. Income level, education level, and employment status are all strong predictors of health care access in the United States.30 The single geographic factor assessed was region of residence (Northeast, Midwest, South, or West). Need-based factors included self-rated health status and presence of children in the household.
Outcomes
We used 4 outcomes in determining health care access: whether respondents had health insurance coverage, whether they had a regular source of health care, whether they had seen a provider in the previous 12 months, and whether they had unmet medical needs as a result of cost issues. Respondents were categorized as having a usual source of health care if they identified a doctor’s office, clinic, or hospital outpatient department, and not a hospital emergency room, as their usual source of care. A provider visit within the preceding 12 months was defined as an interpersonal exchange with a health professional such as a nurse practitioner, physician assistant, general doctor, or medical specialist.
Whether or not respondents had unmet medical needs as a result of cost issues was determined via questions asking respondents whether they had forgone needed medical care in the previous 12 months owing to such issues. Health insurance indicators included insurance status at the time of the interview, whether the policyholder was the respondent or someone else in the household, and whether the respondent’s insurance policy allowed him or her to select any provider or whether the provider had to be selected from a group or list.
Statistical Analysis
The initial data analysis focused on calculating descriptive statistics for all of the variables assessed. Continuous or categorical outcome measures were used to test each variable’s effects on health care access via one-way (repeated measures) analyses of variance or 
2 analyses. We used multiple logistic regression to determine the independent effects of socioeconomic and demographic characteristics on outcomes. If bivariate analyses showed that descriptive variables differed significantly across groups, they were included in the multiple logistic regression as predictors. All regressions were stratified according to gender. All P values were 2-tailed. Analyses were conducted with SUDAAN to incorporate weights reflecting the sampling strategy, adjustment for nonresponse, and the potential effect of cluster sampling in the estimation of standard errors.31
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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. SSR respondents as a whole were younger and more highly educated than OSR respondents, and the SSR population included a significantly larger proportion of men than the OSR population. SSR women were more likely than OSR women to be employed and to live in the northeastern and western United States. Slightly more than half of OSR men and women reported having children living in their household, whereas one fourth of SSR women and few SSR men (5%) reported living with children. SSR women were more likely to be of White non-Hispanic race/ethnicity.
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), SSR women were significantly less likely than OSR women to have health insurance coverage (odds ratio [OR] = 0.60; 95% confidence interval [CI] = 0.39, 0.92). SSR women were at 85% increased odds (95% CI = 1.16, 2.96) of having unmet medical needs as a result of cost issues (Table 3). Regression results showed that SSR women were significantly less likely than OSR women to report having seen a medical provider in the previous 12 months (OR = 0.66; 95% CI = 0.46, 0.95). Also, after control for explanatory variables, SSR women had half the odds of having a usual source of health care (OR = 0.50; 95% CI = 0.35, 0.71).
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Additional Insurance Analyses
In comparison with OSR men and women, significantly higher proportions of SSR men (P = .0001) and women (P < .0001) with insurance coverage were named policyholders (Table 4). After control for explanatory variables, SSR men (OR = 2.08; 95% CI = 1.39, 3.13) and women (OR = 5.26; 95% CI = 3.40, 8.15) were significantly more likely than OSR men and women to have health insurance in their own name (data not shown). The spouses or partners of OSR women and men were significantly more likely than the spouses or partners of SSR women and men to have health insurance coverage.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Our findings highlight the relevance of sexual orientation to health care access in the United States. SSR women fared poorly compared with OSR women across a range of indicators, strongly suggesting that there are important disparities in receipt of health services between these 2 groups. SSR women were less likely than OSR women to visit a doctor or have a regular source of health care, and they were more likely to report experiencing unmet medical needs as a result of cost issues. Although unknown confounders may have produced these results, they are consistent with the findings of other studies.21–23 Possible reasons for disparities between SSR and OSR populations include historical factors (e.g., treatment of homosexuality as a mental illness32) and dissatisfaction with health care services stemming from discrimination on the part of providers or the health care system (for a review, see the Institute of Medicine report mentioned earlier27).
We found notable similarities and differences between male participants. SSR and OSR men were similar in their odds of having unmet medical needs owing to cost issues. SSR men were two thirds more likely than OSR men to have seen a health care provider in the previous year, and there was a trend for these men to be more likely to have a usual source of health care. It is not known why, even after results had been controlled for self-reported health status, SSR men would make greater use of health services. It may be that the HIV epidemic has revolutionized health care among some gay men, making them more likely to have a regular provider, to be open about their sexual orientation, or to seek preventive care for concerns that could be exacerbated by HIV.
It is unclear why there were such disparate findings between SSR women and SSR men. Men in general are known to see health care providers less frequently than women,33 setting "the bar" lower and perhaps making it easier for SSR men to achieve parity with OSR men. The HIV epidemic may have altered the way gay men interact with the health care system, but equivalent changes might not be in evidence among lesbians, in part because of their lower risk for HIV. In addition, a previous study showed that lesbians may have more difficulty than gay men in communicating with health care providers; this finding was attributed to the fact that these women are less willing to disclose their sexual orientation and are more concerned about being able to find a GLB-friendly provider.15
In other studies, SSR women’s health care use may have been influenced by discrimination experienced from their providers.34,35 Findings on gay men’s satisfaction with health care services have been more variable in nature. Although some studies have shown that gay men are disaffected by experiences of stigma in the health care system, other studies have shown that they report their health care experiences as generally positive.16,36
It is notable that rates of health insurance coverage were lower among SSR women than OSR women; this finding might be at least partially attributed to the inability of same-sex couples to marry or form legal partnerships in most states. Marriage is a strong predictor of health insurance coverage in the United States; nationwide, people who have never been married (26.9%) and those who are living with a partner (31.7%) are more likely to be uninsured than those who are married (12.6%).37 In all likelihood, SSR women are more strongly affected than SSR men by an inability to obtain health insurance coverage through their partner. More than 40% of insured women in the United States are covered through another person, as compared with only one fifth of insured men.38 In addition, women are less likely than men to be employed in professions that provide health insurance coverage.13 The present findings in respect to health insurance highlight the need to encourage government and industry to offer health coverage for individuals involved in domestic partnerships.
Having health insurance coverage is a vital factor in health care access. Although a growing number of companies offer health coverage to same-sex domestic partners, few employees use this benefit.39,40 Lack of enrollment and underenrollment have been attributed both to employees not wishing to "come out" at work and to differences in taxation of benefits to nonmarried partners. Little is known about the experiences of GLB individuals as insurance policyholders, nor is it clear how type of health insurance or provider choice may influence use of health care in the GLB population.
We found that similar proportions of SSR and OSR participants reported being able to choose any health care provider under their health plan. A previous study showed that individuals whose insurance plans allowed them to choose a GLB provider were more likely to be older and male; they were also more likely to adhere to their medication regimen and to feel comfortable discussing sex-related issues with a physician.15 Widening the choices of providers in insurance plans may therefore help increase access among SSR individuals as well as change the nature of their interchanges with providers.
Our data reveal the validity of Andersen’s model in predicting patterns of health care use among GLB individuals. An extensive literature has established that health care access and use among adults are influenced by employment status, education level, race/ethnicity, age, socioeconomic status, and location of residence. Health insurance coverage also emerged as a key covariate in our models, illustrating its importance in helping Americans gain access to affordable, regular health services. Similar to the findings of previous studies, younger participants were less likely to have a regular source of health care and were much less likely to be insured than were older participants. Hispanic respondents had less access than respondents in other racial/ethnic groups across all major outcomes, including less than one half the odds of health insurance coverage.
The findings of this study suggest that health educators designing programs to improve access to health services should be aware of the barriers that lesbian patients may face. We encourage the development of outreach programs aimed toward the lesbian community to improve this population’s regular use of health services. Furthermore, our results show the need for improved cultural competence among providers. Although much has changed in recent years, homophobic attitudes persist.41 In some cases, even providers with positive attitudes toward GLB patients report poor knowledge of the needs of these patients; in other cases, providers may be unsure of how to discuss GLB needs with patients without offending them.42,43 At present, many residency programs do not include information on GLB health.44,45 Thus, it is urgent that more information on GLB health needs be provided in residency programs and in continuing education programs designed for primary care providers.
Limitations
This study was limited to individuals living with a partner, and our findings cannot be generalized to those not living with a partner. Individuals living with partners are likely to have greater financial resources that allow them to cover the costs of medical services, putting them at an advantage over single individuals without partners. In addition, the social support gained from close, intimate partnerships has been shown to improve health,46 possibly by increasing healthy behaviors and use of health care services. In this survey, 12% of male and 17% of female SSR respondents with health insurance coverage were covered through their domestic partner or another individual.
The population-based data collection design of the NHIS is a strength of this study. Many studies focusing on GLB populations recruit participants from social venues or GLB health centers, where identification with the GLB community is more likely47; the population-based nature of the NHIS suggests that its findings better represent the partnered GLB population than do the results of other studies. However, the SSR/OSR variable must be viewed as a proxy for sexual orientation, given that participants were not asked directly about their sexual orientation.
Data are not available on whether the sample of SSR adults selected in the NHIS was representative of SSR adults nationally. However, the NHIS was designed and weighted to be representative of US noninstitutionalized adults as a whole.28 Of the 94 032 individuals included in this study, 0.65% reported that they were involved in an SSR, and 99.35% reported they were involved in an OSR. This percentage of same-sex couples was similar to the percentage (0.6%) of such couples reported in the 2000 census,48 and we do not believe that bias due to nonresponse was a significant issue. However, it is likely that not all individuals living with a same-sex partner disclosed their relationship status to interviewers. Census-based estimates indicate that same-sex partnerships are probably undercounted by 13% to 28%,49 although extrapolations from population estimates would suggest undercounts as high as 62%.50 Studies of census data have shown that individuals who do not use "unmarried partner" to designate their SSR are more likely than those who do to have low incomes and to live in the Midwest.49
This study was cross-sectional in design, and thus it is subject to the limitations associated with such research.51 It is difficult to know the full contribution of SSR status to health care access, in that SSR individuals may modify their health care choices to gain access to the care available to them. For example, it is possible that GLB spouses compensate for a lack of partner coverage by altering their employment decisions, deciding that both partners will work, or working for employers that offer coverage for same-sex partners.
Conclusions
Our results confirm those of previous studies indicating that lesbians are at particularly high risk of poor health access. Given that this is one of the largest-scale studies of health care access among individuals in SSRs, our results have several implications for the need to improve access in this group. There is a clear need for targeted outreach to the same-sex community and wider scale training of primary care providers in lesbian health issues. Making health insurance more widely available could increase access to health services, particularly among SSR women. As mentioned, those designing programs to improve access to services should be aware of the barriers faced by lesbian patients.
Future interventions also should emphasize that individuals involved in same-sex partnerships may be less likely to have recently used health care services, and thus they might be at increased likelihood of missing routine health screenings for (and counseling designed to reduce) disease risk factors. Additional population-based surveys involving measures of sexual orientation are suggested.
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Acknowledgments |
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Human Participant Protection
No protocol approval was needed for this study.
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Footnotes |
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Contributors
J. E. Heck originated the study, conducted the analyses, and led the writing. R. L. Sell provided conceptual guidance and helped interpret the findings. S. Sheinfeld Gorin supervised the work. All of the authors reviewed and edited drafts of the article.
Accepted for publication July 29, 2005.
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References |
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