Health Care Delays, Mental Health Care, and Discrimination among US Sexual and Gender Minority Adults: Intersectional Analysis of State-level Policies.

INTRODUCTION

Sexual and gender minority (SGM) individuals experience profound health inequities exacerbated by delays in health care and underutilization of mental health services. This study examined the association of intersectional state-level policy inclusiveness (racial equity, sexual orientation inclusiveness, and gender inclusiveness) with delays in health care, mental health service use, and discrimination in medical settings (DMS) among a sample of SGM adults in the United States.

METHODS

Data were analyzed from 21,701 SGM adults participating in the All of Us Research Program 2021-2023, combined with state-level policy measures: National Equity Atlas' Racial Equity Index, and Movement Advancement Project's sexual orientation inclusiveness and gender identity inclusiveness policy tallies. Using intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (I-MAIHDA), mixed effects logistic and gamma models were built to examine the additive effects and predicted probability of key outcomes by intersectional strata consisting of combinations of state-level policy measures.

RESULTS

The null model showed among SGM adults, intersectional strata explained somewhat more variation in DMS score (2.42%), compared to delay in care (2.13%) and mental health care use (0.58%). The intersectional stratum characterized by a high racial equity index, medium sexual orientation inclusiveness, and low gender identity inclusiveness had the highest predicted delays in health care and DMS scores; the stratum with a low racial equity index, low sexual orientation inclusiveness, and negative gender identity inclusiveness had the lowest predicted mental health service use. The models that included both state-level policy variables and individual characteristics improved precision of estimates, with 53.67% of stratum-level variance explained for delay in health care, 24.06% for mental health service use, and 60.41% for DMS score.

CONCLUSIONS

The results demonstrate that state-level policies across race/ethnicity, sexual orientation, and gender identity are associated with small variations in delays in health care, mental health service use, and DMS scores.