Attitudes Toward Medical Care and Sexual Orientation Identity in Lesbian,Gay,and Bisexual Individuals

Abstract

This study examined factors of lesbian, gay, and bisexual (LGB) identity in relation to general attitudes toward medical care and specific attitudes of medical care avoidance. Through an online questionnaire, 114 participants who self-identified as LGB completed measures of LGB identity and attitudes toward medical care. Out of eight domains of LGB identity, identity affirmation, acceptance concerns, and identity superiority significantly related to overall attitudes toward medical care. In other words, an affirming experience with one's LGB identity significantly related to positive attitudes. Conversely, concerns about judgement for being LGB and beliefs that LGB identity is superior to heterosexual identity related to negative attitudes. Furthermore, stronger overall negative LGB identity significantly related to stronger attitudes of medical care avoidance. These findings suggest that both positive and negative aspects of LGB identity relate to attitudes toward seeking medical care. We discuss the implications of our findings for clinical work with LGB individuals and their loved ones.

Keywords

sexual orientation sexual minorities sexual identity health care attitudes heath-seeking health care sexual orientation attitudes toward medical care

Although access to health care has improved for lesbian, gay, bisexual, and queer (LGB¹) individuals, this population continues to experience both mental and physical health disparities when compared to heterosexual individuals (Gonzales & Henning-Smith, 2017). LGB individuals experience higher prevalence of poor health factors including chronic illness, mental illness, need for medication, need for psychological services, and lack of health insurance or being underinsured (Strutz et al., 2015). In general, LGB individuals are less likely to rate their health as excellent or very good compared to heterosexual individuals (National Center for Health Statistics, 2014). Additionally, LGB individuals are less likely to be satisfied with health care when compared to heterosexual individuals, especially for those who have individually purchased health insurance coverage (Blosnich, 2017). The experiences of LGB individuals within health care are complex and are influenced by a variety of factors, both external and internal. These factors must be examined and understood in order to begin creating approaches to address health disparities and LGB individuals’ engagement with the healthcare system. Because health care encompasses a wide range of provider types, we use the term “medical care” to refer to providers who specifically focus on medical concerns.

Within the domain of psychological well-being and mental health, LGB health disparities have been conceptualized using the Minority Stress Model, which posits that the stress of experiencing stigma, prejudice, and discrimination related to being LGB leads to increased prevalence of mental health problems and disorders, such as depression and anxiety, compared to heterosexual individuals (Meyer, 2003). Although this model and subsequent research has focused primarily on mental health issues, the consequences of minority stress on the body could also reasonably relate to LGB individuals’ attitudes toward and willingness to engage with medical providers. For example, stereotype threat and social identity threat, wherein LGB individuals fear being judged due to negative stereotypes or a devalued identity (Fingerhut & Abdou, 2017), could lead to negative attitudes toward medical care, and thus negatively influence the likelihood that LGB individuals engage with medical care. Furthermore, interactions with medical providers often require individuals to disclose their sexual orientation in order to receive relevant medical care (particularly for sexual and reproductive health), and willingness to approach those interactions might be influenced by internal factors such as the characteristics of an individual's sexual orientation identity. Conversely, some research indicates that fears of rejection or discrimination do not relate to likelihood of sexual identity disclosure to healthcare providers (Durso & Meyer, 2013). The threat to self-esteem model suggests that individuals’ reaction to aid depends upon a mixture of both self-threatening and supportive factors (Fisher et al., 1982; Nadler & Fisher, 1986). For LGB individuals, being open about their sexual orientation with a medical provider may be difficult due to threat to self-esteem, and as a result LGB individuals may choose to avoid disclosing their sexual orientation or avoid medical care altogether. Research focusing on bisexual individuals indicates that anti-bisexual experiences with mental health providers negatively impact individuals’ help-seeking intentions (DeLucia & Smith, 2021).

As a complex component of overall identity, sexual orientation identity in LGB individuals is comprised of multiple factors, both positive and negative. In a qualitative study, Riggle et al. (2008) found that many positive aspects of being lesbian or gay revolved around involvement in the lesbian and gay community. In addition, the process of exploring one's sexual identity helps with the development of identity affirmation, wherein LGB individuals have positive attitudes toward their sexual orientation and feel a sense of belonging to the LGB community (Ghavami et al., 2011). Conversely, due to discrimination and prejudice related to sexual orientation, LGB individuals also experience negative aspects of sexual orientation identity. Internalized homonegativity, wherein individuals internalize negative stereotypes and assumptions related to being LGB, is among the most commonly researched negative LGB identity factor and ties into health issues faced by the LGB population (Meyer, 2007; Williamson, 2000). Higher levels of internalized homonegativity relates to lower likelihood of disclosing sexual orientation to healthcare providers (Durso & Meyer, 2013). Other negative identity components include difficult process, referring to difficulties associated with LGB identity development, as part of navigating LGB identity development, and motivation to conceal identity as a result of prejudice and discrimination (Mohr & Kendra, 2011). Overall, the composition of any identity is complex, and from a broad perspective LGB identity is comprised of interactive positive and negative factors that are experienced differently across individuals (Ashmore et al., 2004; Mohr & Kendra, 2011).

Researchers have investigated sexual orientation identity in terms of implications for prevalence and experience of mental health disorders and psychological well-being. For example, greater identity integration, where LGB individuals view their sexual orientation as a positive aspect of their overall identity, relates to decreased mental health symptoms and increased psychological well-being in LGB youths (Rosario et al., 2011). Similarly, positive identity factors relate to various aspects of psychological well-being, including positive relations with others, self-acceptance, purpose in life, and feelings of autonomy (Rostosky et al., 2018). Although mental health and mental healthcare delivery differs from physical health and medical care, sexual orientation identity may also influence the experiences of LGB individuals within the context of medical care. For example, Williamson (2000) discusses the role of internalized homonegativity, a component of LGB identity, and its relation to negative behaviors toward oneself and subsequent negative impacts on health factors such as HIV risk and progression, substance use, and suicide risk. Similarly, higher levels of internalized homonegativity and lower levels of perceived connection to the LGB community relates to lower likelihood of disclosing sexual orientation to healthcare providers (Durso & Meyer, 2013). This perspective could potentially extend to health seeking and medical care engagement where internalized homonegativity and other negative identity components might negatively relate to LGB individuals’ attitudes toward and subsequent engagement with medical services.

Several barriers to medical care within the LGB community in the United States stem from lack of health insurance or lack of engagement with medical providers (Strutz et al., 2015). Theories of medical help-seeking suggest that “predispositions” to seeking care, such as cognitive-attitudinal factors, are a key component of the decision to engage with health care (Andersen, 1995). Given the disparities experienced by LGB individuals, attitudes toward medical care are an area of potential influence in health disparities. Similarly, negative attitudes could relate to decreased engagement with medical care such as denying or avoiding early symptoms of a health problem that would presumably lead to less positive health outcomes. A grounded-theory study focusing on bisexual individuals indicates that predisposing factors such as general stigma around being bisexual, fear of discrimination, and past negative experiences with care, all of which could result in negative attitudes toward care, negatively influenced participants’ intentions of seeking care (MacKay et al., 2017). Conversely, engaging in healthcare seeking behaviors might stem in part from positive attitudes toward health care and medical professionals. That is, LGB individuals who feel affirmed and supported in their identity may be less likely to develop negative attitudes toward medical care.

Within the behavioral health domain, factors of sexual orientation identity significantly relate to psychological help-seeking attitudes in LGB individuals (Spengler & Ægisdóttir, 2015). Identity affirmation, which includes positive attitudes regarding one's sexual orientation as well perceiving support from the community, positively relates to increased help-seeking attitudes. Furthermore, negative LGB identity relates to decreased psychological help-seeking attitudes (Spengler & Ægisdóttir, 2015). Unfortunately, researchers have not studied whether the relation between internal LGB identity factors and attitudes toward help-seeking similarly apply to the domain of medical care. In the current study, we aim to extend Spengler & Ægisdóttir's (2015) research by examining how LGB identity factors relate to attitudes toward medical care.

Because sexual orientation identity is a multidimensional construct containing various factors with both positive and negative implications for health and well-being, the current study aims to evaluate both positive and negative factors of LGB identity as they relate to attitudes toward medical care using self-report measures. Given the limited research examining how factors of LGB identity relate to attitudes toward medical care, we first examined a model where eight factors of LGB identity (acceptance concerns, concealment motivation, identity uncertainty, internalized homonegativity, difficult process, identity superiority, identity affirmation, and identity centrality) are considered in relation to overall attitudes toward medical care. We hypothesized that identity affirmation and internalized homonegativity would significantly relate to attitudes toward medical care; however, given that other aspects of LGB identity are less frequently researched, we included additional factors as part of a broader exploratory perspective. In addition, we examined how LGB negative identity (a composite construct comprised of several negative identity factors) relates to overall attitudes toward medical care with specific hypotheses that negative LGB identity would relate to more negative general attitudes toward medical care as well as stronger attitudes of medical care avoidance. We examined these concepts because of the important implications for clinical work with LGB individuals and their loved ones.

Method

Procedure

Participants were recruited through Reddit, an online forum open to public access. We posted an invitation to the study on Reddit periodically over the course of 10 months, which requested participation in an anonymous online research study about sexual identity and views of medical care. Participants accessed the anonymous online survey in Qualtrics via a link in the study invitation post. Upon opening the link, participants were provided with information about the study including that anyone over the age of 18 who currently lives in the United States was eligible to participate, and that participation would result in no direct benefit to participants. Participants were then asked whether they consented to participate in the study and whether they were at least 18 years of age. If they answered “No” to either of these questions, they were thanked for their participation and the survey closed. Those who provided informed consent and affirmed their age of at least 18 years were directed to begin answering survey questions. Participants who self-identified as lesbian, gay, bisexual, queer or otherwise not heterosexual (i.e., LGB) completed a demographic questionnaire, the AMC scale, and the LGBIS scale. Prior to data collection, this study was reviewed by a university Institutional Review Board.

Participants

Of the 367 individuals who opened the hyperlink to the online questionnaire, we retained 114 (31%) participants who identified as LGB for analyses. The remaining participants were excluded because they identified as heterosexual or did not complete enough information to be included in analyses.

Table 1 presents demographic information about participants’ sexual orientation, gender, race/ethnicity, annual household income, education level, and relationship status. Participant age ranged from 18 to 50 years (M = 24.53, SD = 6.05), and one participant did not report age. Most participants reported having health insurance (n = 107, 93.9%) with a small portion not having health insurance (n = 6, 5.3%) and one (.9%) participant who did not answer. Similarly, 75 (65.8%) participants had a primary care provider (PCP) and 39 (34.2%) did not have a PCP.

Table 1.
Sample Demographic Characteristics (n = 114).

Characteristic n (%)

Sexual orientation

Lesbian 11 (9.6)

Gay 12 (10.5)

Bisexual or pansexual 53 (46.5)

Queer 13 (11.4)

Another non-heterosexual orientation 25 (21.9)

Gender identity

Cisgender man 23 (20.2)

Cisgender woman 52 (45.6)

Transgender, non-binary, or another gender 39 (34.2)

Race/ethnicity

White or European American 91 (79.8)

Black, African, or African American 1 (.9)

Hispanic, Latino, Chicano, or Spanish origin 4 (3.5)

American Indian or Alaska Native 1 (.9)

Asian or Asian American 4 (3.5)

Biracial or Multiracial 9 (7.9)

Unknown 4 (3.5)

Annual household income

$0-$20,000 per year 23 (0.2)

$20,000-$50,000 per year 25 (21.9)

$50,000-$75,000 per year 20 (17.5)

$75,000 or more per year 28 (32.5)

Unknown 18 (15.8)

Education level

Primary school or some high school 5 (4.4)

High school diploma or GED 18 (15.8)

Associates degree, technical degree, or some college 32 (28.1)

Bachelor's degree 42 (36.8)

Graduate degree (e.g., master's, PhD, MD, JD, etc.) 16 (14)

Unknown 1 (.9)

Relationship status

Single 51 (44.7)

Dating or in a relationship 44 (38.6)

Engaged 2 (1.8)

Married 14 (12.3)

Domestic partnership 1 (.9)

Divorced or separated 1 (.9)

Unknown 1 (.9)

Measures

Demographic Questionnaire. Demographic and background items asked participants to report their age in years, sexual orientation, gender identity, race/ethnicity, relationship status, annual household income, education level, health insurance status, and whether they had a PCP.

Attitudes Toward Seeking Medical Care. The Attitudes Toward Medical Care (AMC) scale (Fischer et al., 2013) was used to measure participants’ attitudes toward seeking medical care. The AMC is a 35-item measure divided into four subscales: Pro-Action, Nonfatalistic, Med Trust, and Non-Avoidant. Items on the AMC are evaluated using a 4-point Likert-type scale ranging from 0 (disagree) to 3 (agree). Higher scores indicate more positive attitudes toward medical care and lower scores indicate more negative attitudes. The overall attitude score is comprised of the summed scores for each item with possible scores ranging from 0 to 105.

The Pro-Action subscale reflects the action-intention component in seeking medical care. That is, this subscale describes general intentions of seeking medical care when needed and higher scores reflect more positive intentions of seeking care when needed. The Nonfatalistic subscale characterizes an acceptance versus cynical attitude toward medical care. Higher scores reflect lack of this cynicism, whereas lower scores reflect perspectives that medical care is not helpful for health problems, and that seeking care will not cause positive change in health problems. The Med Trust subscale reflects affirmative attitudes toward medical care such having confidence that medical providers are knowledgeable and competent to help with medical issues. Higher scores reflect higher levels of trust in medical providers, procedures, and interventions. The Non-Avoidant subscale characterizes the procrastination-avoidance-fear component of seeking medical care. That is, this subscale captures thoughts and attitudes of avoiding or delaying medical care even when acknowledged as necessary. Higher scores reflect little avoidance, whereas lower scores indicate higher levels of avoidance.

Factor analysis, both during initial scale development and with a subsequent community sample, supported a four-factor solution characterized by the measure's subscales (Fischer et al., 2013); however, factor analysis of the AMC scale has not been specifically conducted with an LGB sample. Reliability analyses for the current study indicate that Cronbach's α was .93 for the overall scale, .91 for Pro Action, .86 for Nonfatalistic, .83 for Med Trust, and .84 for Non-Avoidant, which was similar to previously reported internal consistency reliability (DiLorenzo et al., 2015; Fischer et al., 2013). Fischer et al. (2013) established concurrent validity by illustrating that the AMC was comparable to an interview protocol of attitudes toward seeking medical help (see Sharp et al., 1983). The authors also established predictive validity by presenting significant correlations between AMC scale scores and measures of actual medical contacts (Fischer et al., 2013). Further predictive validity for the Pro Action subscale, or action-intention component, of the AMC scale was demonstrated via correlation between subscale score and medical contacts or intentions over time (DiLorenzo et al., 2015).

LGB Identity. The Lesbian, Gay, and Bisexual Identity Scale (LGBIS; Mohr & Kendra, 2011) was used to measure factors of participants’ sexual identity. The LGBIS is a 27-item measure divided into eight dimensions: Acceptance Concerns, Concealment Motivation, Identity Uncertainty, Internalized Homonegativity, Difficult Process, Identity Superiority, Identity Affirmation, and Identity Centrality. Items are measured using a 6-point Likert-type scale ranging from 1 (disagree strongly) to 6 (agree strongly). For the mean scores of LGBIS subscales, higher scores reflect more intense experience of that identity factor and lower scores indicate less intense experience. For example, high scores on Identity Affirmation indicate positive feelings associated with one's sexual identity.

The eight subscales of Mohr and Kendra’s (2011) LGBIS have the following conceptual definitions: (a) Concealment Motivation reflects motivation to keep one's LGB identity private, (b) Identity Uncertainty reflects uncertainty around one's sexual orientation identity, (c) Internalized Homonegativity reflects internal rejection and negative evaluation of one's sexual orientation identity, (d) Difficult Process reflects perceptions that the development of one's sexual orientation identity was difficult, (e) Acceptance Concerns reflects concerns about others’ acceptance of one's sexual orientation identity, (f) Identity Superiority reflects perceptions that LGB individuals are favored over heterosexual individuals, (g) Identity Centrality reflects the degree to which one's sexual orientation identity is central to one's overall identity, and (h) Identity Affirmation reflects the degree to which one associates positive thoughts and emotions with one's sexual orientation identity and with the LGB community.

Mohr and Kendra (2011) suggested analyzing subscale scores independently except for four subscales that loaded onto a second-order factor (i.e., Negative Identity) representing overall difficulty related to one's sexual identity as an LGB person. These subscales were Internalized Homonegativity, Concealment Motivation, Acceptance Concerns, and Difficult Process. Based on Mohr and Kendra (2011) finding of negative identity as a second-order factor and on Spengler and Ægisdóttir's (2015) use of the LGBIS in examining psychological help seeking, we chose to combine these four subscales to represent LGB Negative Identity in addition to use of individual subscales. Higher scores on Negative Identity tend to indicate earlier stages in sexual orientation identity development for LGB individuals, negative psychological functioning, and low satisfaction with life (Mohr & Kendra, 2011).

Reliability analyses for the current study indicate that Cronbach's α was .71 for Acceptance Concerns, .81 for Concealment Motivation, .86 for Identity Uncertainty, .88 for Internalized Homonegativity, .73 for Difficult Process, .86 for Identity Superiority, .92 for Identity Affirmation, .77 for Identity Centrality, and .83 for the Negative Identity composite. These values were similar to those found by Mohr and Kendra (2011). In addition, Mohr and Kendra (2011) established criterion-related validity by demonstrating significant relationships between each LGBIS subscale and relevant identity-related psychosocial functioning measures.

Results

The means, standard deviations, and Cronbach's α for the AMC composite score and Non-Avoidant subscale score are presented in Table 2. The AMC composite scores for our sample of 114 participants were normally distributed, although the average was slightly shifted in the pro-help seeking direction, indicating that in general participants had positive overall attitudes toward medical care. Similarly, the AMC Non-Avoidant average scores were slightly shifted in the positive direction, indicating that participants generally did not have strong attitudes of avoidance regarding medical care. Each of the LGBIS subscale means, standard deviations, and Cronbach's α are also presented in Table 2. On average, participants scored strongly in the positive direction on the Identity Affirmation subscale, indicating a high degree of associating positive thoughts and feelings with their sexual orientation. Similarly, participants scored near the midpoint on average for the Acceptance Concerns, Concealment Motivation, and Identity Centrality subscales. Conversely, participants scored slightly in the negative direction for the Identity Superiority and Identity Uncertainty subscales. For the Internalized Homonegativity subscale participants scored strongly in the negative direction, indicating that participants generally experienced low levels of internalized homonegativity.

Table 2.
Reliability, Means, and Standard Deviations for Assessed Constructs (n = 114).

Variable Cronbach's α M SD

AMC Composite .93 69.75 16.67

AMC Non Avoidance .84 9.85 3.74

Identity Affirmation .92 4.67 1.19

Acceptance Concerns .71 3.57 1.23

Identity Superiority .86 2.08 1.18

Concealment Motivation .81 3.65 1.37

Identity Uncertainty .86 2.09 1.12

Internalized Homonegativity .88 1.74 1.09

Difficult Process .73 3.11 1.20

Identity Centrality .77 3.71 1.05

Negative Identity^a .83 3.02 .87

Note. AMC = Attitudes Toward Medical Care.

^a
Negative Identity is a composite score derived from Acceptance Concerns, Concealment Motivation, Internalized Homonegativity, and Difficult Process as described in Mohr and Kendra (2011) and Spengler and Ægisdóttir (2015).

Linear regression was used to examine relations among factors of LGB identity and attitudes toward medical care. In the following sections we first discuss the overall model of LGB identity as it relates to the overall composite score of attitudes toward medical care. We then discuss our models containing a composite score of LGB negative identity as it relates to overall attitudes toward medical care as well as attitudes of medical care avoidance.

LGB Identity and Overall Attitudes Toward Medical Care

In relation to our exploratory question regarding how factors of LGB identity relate to an overall composite measure of attitudes toward medical care, a multiple linear regression model including eight factors of LGB identity (Acceptance Concerns, Concealment Motivation, Identity Uncertainty, Internalized Homonegativity, Difficult Process, Identity Superiority, Identity Affirmation, and Identity Centrality) showed that the linear combination of these factors significantly relate to overall scores of attitudes toward medical care as measured by the AMC composite score, R² = .24, R²_adj = .18, F(8, 105) = 4.11, p < .001. This indicates that approximately 24% of the variance of overall attitudes towards medical care is accounted for by the linear combination of LGB identity variables.

Of the eight factors of LGB identity included in the model, three emerged as significantly related to overall AMC scores: Identity Affirmation (B = 5.35, p < .01, 95% CI [1.86, 8.84]), Acceptance Concerns (B = −4.19, p < .01, 95% CI [−7.17, −1.21]), and Identity Superiority (B = −3.67, p = .01, 95% CI [−6.55, −.79]). These results indicate that Concealment Motivation, Identity Uncertainty, Internalized Homonegativity, Difficult Process, and Identity Centrality do not significantly relate to overall attitudes toward medical care.

Several Pearson correlations among the eight LGB identity variables were statistically significant ranging from small to large in strength (refer to Table 3). Therefore, the multiple regression model was assessed for multicollinearity using Variance Inflation Factor (VIF). The VIF for each variable was less than 10 with an average VIF of 1.78. These results indicated no evidence of multicollinearity influencing the regression model. Similarly, the Durbin-Watson test was 1.91, which indicates no first order autocorrelation was present in the model.

Table 3.
Intercorrelations Among Assessed Constructs in Overall Model of LGB Identity and Attitudes Toward Medical Care (n = 114).

Variable 1 2 3 4 5 6 7 8

1. AMC Composite

2. Identity Affirmation .095

3. Acceptance Concerns −.321 −.026

4. Concealment Motivation −.003 −.466 .265

5. Identity Uncertainty −.063 −.102 .235 .099

6. Internalized Homonegativity −.011 −.514 .272 .371 .232

7. Difficult Process −.047 −.198* .470 .270 .441 .435

8. Identity Superiority −.288 .351 .218* −.313** .009 −.173* .121

9. Identity Centrality −.180* .657 .232 −.459 −.113 −.347 −.060 .515**

*p < .05. **p < .01.

LGB Negative Identity

The composite score of negative aspects of LGB identity (i.e., LGB Negative Identity) and its relation to overall attitudes toward medical care as well as specific attitudes of medical care avoidance was assessed using simple linear regression. Contrary to our hypotheses, LGB Negative Identity scores did not significantly relate to overall AMC scores, indicating that experience of general negative aspects of LGB identity do not relate to overall attitudes toward medical care, B = −1.53, R² = .02, R²_adj = .009, F(1, 112) = 2.05, p = .16. However, LGB Negative Identity was negatively linearly related to scores on the AMC Non-Avoidant subscale (r = −.36). This suggests that as scores on the LGB Negative Identity subscale decrease, attitudes of non-avoidance (i.e., willingness to seek medical care when needed) increase, B = −1.53, R² = .13, R²_adj = .12, F(1, 112) = 16.33, p < .001. Approximately 13% of the variance in non-avoidant attitudes was accounted for by LGB Negative Identity.

Discussion

To understand why LGB people have historically experienced health disparities (Gonzales & Henning-Smith, 2017; Strutz et al., 2015) as well as low satisfaction with health care compared to their heterosexual peers (Blosnich, 2017), it is important to examine the underlying external and internal mechanisms that may impact LGB individuals engagement with medical care. In this study, we investigated whether aspects of sexual orientation identity (i.e., internal factors) related to attitudes toward medical care. We examined an exploratory model containing eight factors of LGB identity as they relate to overall attitudes toward medical care. We also examined the relation between general LGB negative identity and both overall attitudes toward medical care as well as specific attitudes of medical care avoidance. Our study yielded four main findings. We discuss our findings considering implications for LGB clients and their loved ones.

First, we found that higher identity affirmation scores related to more positive overall attitudes toward medical care. The composite overall attitudes toward medical care measure included intentions of seeking medical care when needed, views that medical care is helpful for health problems, trust and confidence in medical providers, and avoidant attitudes toward seeking medical care. Given that identity affirmation relates to later stages of sexual identity development in which individuals experience acceptance of themselves and integration of their sexual orientation with their overall identity (McCarn & Fassinger, 1996; Shepler & Perrone-McGovern, 2016), it makes sense that people high in identity affirmation may be more comfortable approaching medical providers to whom they may need to disclose their sexual orientation for medical reasons. Previous research indicates that interventions aimed at increasing salience of positive factors of LGB identity (i.e., listening and writing about positive identity experiences) leads to immediate and lasting increases in overall positive identity (Riggle et al., 2014). The findings from our study suggest that LGB clients with higher identity affirmation are more likely to have more positive attitudes towards medical care.

Clinically, it may be useful to discuss identity affirmation with LGB clients to support their development toward strong identity affirmation and address challenges they may face in developing a positive perception of their sexual orientation identity and the general LGB community. Discussing identity affirmation in a therapeutic setting may help reduce premature termination with psychotherapy and may support intentions to engage with medical care for individuals who have medical needs. Similarly, clinicians might work with loved ones of LGB individuals to support identity affirmation by processing reactions to a loved one coming out for example.

Second, we found that higher levels of concerns about LGB acceptance were related to more negative overall attitudes toward medical care. This finding is consistent with previous research findings that universal signs of acceptance in medical offices and options for “significant other or domestic partner” on intake forms is associated with increased trust in medical providers (Quinn et al., 2015). Acceptance concerns as an identity factor ties into the minority stress model as well as the threat to self-esteem model, both of which suggest that prejudice and discrimination, either expected or actual, negatively impact the well-being of LGB individuals, and negatively impact LGB individuals’ reactions to offered care (Fisher et al., 1982; Meyer, 2003, 2007; Nadler & Fisher, 1986). A notable portion of participants in our study scored above the midpoint for acceptance concerns with the average near the neutral midpoint, indicating that this identity factor continues to be part of sexual orientation identity experience for many LGB individuals. Given the relation between acceptance concerns and medical care attitudes in our study, further examination of how LGB individuals’ experience of acceptance, or lack thereof, impacts medical care attitudes and experiences is warranted in future studies. Further research could also examine how experiences of acceptance from loved ones impact LGB individuals’ willingness to seek medical and disclose their sexual orientation to medical providers.

From a clinical perspective, the relation been acceptance concerns and attitudes toward medical care highlights the importance of supporting all clients in their diversity so that they are more confident disclosing non-visible diversity variables such as sexual orientation identity. If LGB clients perceive that their providers are open and supportive, they may be less likely to experience acceptance concerns related to their sexual orientation identity, which may increase the likelihood that those LGB clients will disclose their identity. Providers can support loved ones of LGB individuals by helping them process and resolve any negative reactions regarding the LGB identity of loved ones without unduly impacting their loved ones or their relationship with loved ones.

Third, we found that stronger beliefs that one's LGB identity is superior or more favorable in some way to heterosexual identity (i.e., identity superiority) related to more negative overall attitudes toward medical care. This finding was unexpected, and little past research involving identity superiority in LGB individuals exists. This construct may be related to feelings of pride in oneself as an LGB person or to aversion toward heterosexual people. Conversely, identity superiority could be related to early stages of LGB identity development, during which negative perceptions of heterosexual individuals sometimes occur as a reaction to prejudice and discrimination experienced and expected in a heterosexual dominant society (McCarn & Fassinger, 1996). Further research on feelings of identity superiority should address relations with help-seeking behaviors and wellbeing to understand its impact on LGB individuals.

LGB clients who may not be as far along in their LGB identity development might benefit from working with a therapist to process their experience as their identity continues to the develop over time. Psychoeducation about models of LGB identity (e.g., McCarn & Fassinger, 1996) may be beneficial for these clients. Loved ones of LGB individuals may also benefit from understanding models of LGB identity development to support their understanding of why the experiences of their LGB loved ones may change over time. Understanding general LGB identity development may also help loved ones support LGB individuals through difficulties experienced with identity development and improve likelihood of LGB individuals seeking medical care when needed.

Fourth, in addition to our exploratory model, we also examined general LGB negative identity in relation to overall attitudes toward medical care and more specifically attitudes of medical care avoidance. Unexpectedly, we found no significant relation between general negative identity and overall attitudes toward medical care, unlike previous research indicating that negative LGB identity relates to lower levels of psychological help-seeking (Spengler & Ægisdóttir, 2015). This difference between how negative aspects of sexual orientation relate differently to medical versus psychological health care may indicate that minority stress experienced by LGB individuals impacts trust and attitudes toward mental health professionals, but not attitudes toward medical care. We speculate that sexual orientation and the difficulties that can surround sexual identity may be more salient, and potentially more relevant, in mental health settings versus medical settings.

Although LGB negative identity was not related to overall attitudes toward medical care in LGB individuals, when we examined the relation between LGB negative identity and specific attitudes of medical care non-avoidance (i.e., willingness to seek medical care when needed) we found that higher levels negative identity related to stronger avoidance attitudes. This finding is reasonable given that acceptance concerns and concealment motivation comprise two of the four subscales included within LGB negative identity, along with internalized homonegativity and difficult process. Acceptance concerns and concealment motivation capture issues and fears related to revealing one's sexual orientation to others. For both of these identity factors, participants scored near the scale midpoint on average with a notable portion scoring above midpoint, indicating that LGB individuals continue to experience fears around disclosure of their sexual orientation, lack of acceptance from others once disclosed, and motivation to keep their sexual orientation identity private. The relation between LGB negative identity factors and attitudes of medical care avoidance is particularly interesting given that only 65.8% of our sample reported having a PCP, though 93.9% reported having health insurance, which may reflect the possibility that LGB individuals have access to health care but are choosing not to engage with primary care medical providers. An alternative possibility is that individuals may be more likely to have avoidant attitudes toward medical care due to lack of an established PCP or unfamiliarity with seeking medical care. Future research should evaluate whether interventions aimed at reducing experience of negative identity or salience of negative identity factors within LGB individuals ultimately result in increased likelihood of engaging with needed health care, and whether having an established PCP influences the relation between negative identity and medical care avoidance attitudes. Because LGB negative identity factors tend to relate to earlier staged of LGB identity development (e.g., McCarn & Fassinger, 1996; Meyer, 2007; Mohr & Kendra, 2011), our finding that negative identity relates to increased attitudes of medical care avoidance suggests that supporting LGB identity development in a clinical setting could be of therapeutic use for LGB clients working through identity development difficulties. Similarly, our finding also supports the use of psychoeducation around LGB identity development for loved ones of LGB individuals to further promote an environment of acceptance for LGB individuals.

Limitations

We recruited participants over an online forum and this sampling method includes several methodological limitations. The sample in our study may not represent the experiences of the overall LGB population in the United States. Although our participant demographics were generally normally distributed across gender, education level, annual household income, and relationship status, the majority of our sample identified as White which may have led to skewed representation of LGB identity factors that underrepresents the experiences of people of color. Future research in this area could include stratified sampling methods or focus primarily on the experiences of LGB people of color. In addition, our survey did not include a social desirability scale which limited our ability to statistically assess or adjust for social desirability bias. Social desirability could have skewed our results such that participants minimized their experiences of negative identity factors or over-emphasized pro-help seeking attitudes toward medical care. However, the anonymous internet-based nature of our sample and the lack of compensation or benefit for participants limits the potential impact of social desirability bias.

Due to the cross-sectional and exploratory nature of our data collection and analyses, we were not able to establish directionality of the relation between LGB identity factors and attitudes toward medical care. Future research should examine how identity affects future behaviors and whether changes in identity over time lead to changes in attitudes toward medical care over time. Future studies could examine interventions aimed at impacting positive aspects of sexual orientation identity or medical care attitudes, with the goal of determining a potential mechanism for improving one or both factors in LGB individuals. Furthermore, the potential impact of medical care experiences (negative and positive) should be examined with respect to potential influences on LGB identity factors and identity development. In addition, our research did not consider health history, including the health status of participants and participants’ history of engagement with medical care. Because health history could influence the relation between identity and attitudes toward medical care, future reach should either control for health history or include it as a covariate.

Further, our study did not examine within-group differences in identity based on differences in identified sexual orientation. Our data analyses combined individuals identifying as lesbian, gay, bisexual, queer, or otherwise not heterosexual into one group without controlling for the unique experiences of different sexual orientations within the LGB community. Our sample demographics indicate a diverse array of sexual orientations that should be considered separately in future research. Some research has demonstrated a variety of within-group differences across sexual orientation that might influence the relation between identity and attitudes (Worthington & Reynolds, 2009). However, other research indicates that although differences in stages of identity development affect psychological distress and self-esteem, differences in identified sexual orientation do not (Shepler & Perrone-McGovern, 2016). Although fluidity of sexual orientation has been well established and interacts with gender identity (Diamond, 2016; Diamond et al., 2017), our study did not consider the potential effect of fluidity on identity factors for LGB individuals, particularly for those whose sexual attractions vary more widely throughout their lifespan.

Finally, age was not included as a possible covariate in our analysis. Our study incorporated an identity measure that was designed to measure presence and intensity of identity factors, rather than the path of sexual orientation identity development over the lifespan. Given that age can relate to sexual identity development as well as differing medical care needs and experiences across the lifespan, further research should incorporate age as a potential confound of the relation between identity and medical care attitudes. Our sample was limited to adults 18 years due to potential confounding factors associated with age, identity development, and physical development in children and youth.

Conclusion

Our study examined the relation between a variety of LGB identity factors and attitudes toward seeking medical care. Although we did not measure behaviors related to seeking and engaging with medical care, understanding the relation between identity and attitudes provides a basis for future research regarding health-seeking behaviors and potential interventions to improve LGB individuals’ engagement with medical care. Future research should focus on how changes in LGB identity factors affect attitudes over time as well as subsequent health-seeking behaviors and engagement with medical care.

Our findings suggest that both positive and negative aspects of LGB identity relate to attitudes toward medical care and provide a basis for future research to improve LGB health engagement. Aspects of LGB identity could serve as potential targets of intervention on an individual, family, group, or organizational level to improve LGB individuals’ attitudes toward and willingness to seek medical care. Specifically, our data suggest that identity affirmation, concerns related to medical care providers’ acceptance of diverse sexual orientations, and overall experience of negative LGB identity are tied to LGB individuals’ general attitudes toward medical care and attitudes of medical care avoidance. These relations between LGB identity and attitudes toward medical care contribute to understanding the complex interaction of LGB individuals and medical care. Because attitudes are tied to subsequent medical care seeking behaviors (Andersen, 1995), identity could be a helpful point of understanding and potential intervention for LGB individuals and their loved ones. Given that LGB people experience health disparities and report negative interactions with health care (Gonzales & Henning-Smith, 2017; National Center for Health Statistics, 2014; Strutz et al., 2015), understanding the interaction between identity and medical care attitudes provides a basis for future research and interventions to improve LGB health.

Our research has important implications for clinical practice wherein exploring LGB identity factors through individual, couple, or family therapy could be helpful when individuals have hesitations about seeking medical care. Understanding the relation between LGB identity and attitudes toward medical care could also inform clinical work with families and loved ones of LGB individuals who may need to be involved in LGB individuals’ care. Our results may also have utility for medical providers by supporting the need for education around LGB cultural competence that enables the provision of a more welcoming and accepting medical environment for LGB individuals.

Characteristic	n (%)
Sexual orientation
Lesbian	11 (9.6)
Gay	12 (10.5)
Bisexual or pansexual	53 (46.5)
Queer	13 (11.4)
Another non-heterosexual orientation	25 (21.9)
Gender identity
Cisgender man	23 (20.2)
Cisgender woman	52 (45.6)
Transgender, non-binary, or another gender	39 (34.2)
Race/ethnicity
White or European American	91 (79.8)
Black, African, or African American	1 (.9)
Hispanic, Latino, Chicano, or Spanish origin	4 (3.5)
American Indian or Alaska Native	1 (.9)
Asian or Asian American	4 (3.5)
Biracial or Multiracial	9 (7.9)
Unknown	4 (3.5)
Annual household income
$0-$20,000 per year	23 (0.2)
$20,000-$50,000 per year	25 (21.9)
$50,000-$75,000 per year	20 (17.5)
$75,000 or more per year	28 (32.5)
Unknown	18 (15.8)
Education level
Primary school or some high school	5 (4.4)
High school diploma or GED	18 (15.8)
Associates degree, technical degree, or some college	32 (28.1)
Bachelor's degree	42 (36.8)
Graduate degree (e.g., master's, PhD, MD, JD, etc.)	16 (14)
Unknown	1 (.9)
Relationship status
Single	51 (44.7)
Dating or in a relationship	44 (38.6)
Engaged	2 (1.8)
Married	14 (12.3)
Domestic partnership	1 (.9)
Divorced or separated	1 (.9)
Unknown	1 (.9)

Variable	Cronbach's α	M	SD
AMC Composite	.93	69.75	16.67
AMC Non Avoidance	.84	9.85	3.74
Identity Affirmation	.92	4.67	1.19
Acceptance Concerns	.71	3.57	1.23
Identity Superiority	.86	2.08	1.18
Concealment Motivation	.81	3.65	1.37
Identity Uncertainty	.86	2.09	1.12
Internalized Homonegativity	.88	1.74	1.09
Difficult Process	.73	3.11	1.20
Identity Centrality	.77	3.71	1.05
Negative Identity^a	.83	3.02	.87

Variable	1	2	3	4	5	6	7	8
1. AMC Composite
2. Identity Affirmation	.095
3. Acceptance Concerns	−.321**	−.026
4. Concealment Motivation	−.003	−.466**	.265**
5. Identity Uncertainty	−.063	−.102	.235**	.099
6. Internalized Homonegativity	−.011	−.514**	.272**	.371**	.232**
7. Difficult Process	−.047	−.198*	.470**	.270**	.441**	.435**
8. Identity Superiority	−.288**	.351**	.218*	−.313**	.009	−.173*	.121
9. Identity Centrality	−.180*	.657**	.232**	−.459**	−.113	−.347**	−.060	.515**

Footnotes

ORCID iD

Jane M. Tram

Notes

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