The influence of care continuity and disclosure of sexual orientation in general practice on lesbian, bi+ and queer cisgender women’s engagement with mental health services

Introduction

While lesbian, bi+ (i.e. bisexual, pansexual and other identities characteristic of attraction to more than one gender) and queer (LBQ+) cisgender women¹ have been found to use mental health services more frequently than heterosexual women and sexual minority men (McNair et al. 2011; Cronin et al. 2021), they have greater unmet mental health needs (McDermott et al. 2018; Grant et al. 2020; Carpenter 2021; Cronin et al. 2021). A potential explanation for this phenomenon is that many people who are lesbian, gay, bisexual, trans, intersex, queer or questioning, asexual, and other diverse sexuality and gender identities (LGBTIQA+) experience challenges to engaging with the health system and forego care due to anticipation of discrimination and medical gatekeeping (McDermott et al. 2018; Grant et al. 2020; Carpenter 2021; Cronin et al. 2021). The mental health inequalities observed for LBQ+ cisgender women compared to their heterosexual counterparts (Hughes et al. 2010; McNair and Bush 2016) are therefore influenced by the impact of living in a society that discriminates against sexual minorities and the barriers this confers to engaging with health care. One recent study showed that 70% of LGBQ cisgender people indicating clinical levels of distress hadn’t accessed mental health care in the past 6 months, and almost one-fifth had never done so despite feeling it would be beneficial (Cronin et al. 2021). Similar behaviours have been noted in LBQ+ women populations, in which two-fifths of those participating in a previous study believed they needed mental health or alcohol-related support but had never accessed it (McNair et al. 2018).

General practitioners (GPs) provide accessible health promotion, primary physical and mental health care and referral to specialist mental health providers. Continuity of care is a core component of quality general practice care, with studies of the general population showing that people who access multiple GPs report lower levels of preventive health screening, satisfaction with care and confidence in their doctors (Glenister et al. 2021). GPs are the most frequently accessed health professionals among LBQ+ cisgender women (McNair and Bush 2016), yet this group still remains less likely than heterosexual cisgender women to report care satisfaction and continuity with their GP (McNair et al. 2011)

Importantly, non-disclosure of minoritised sexual orientation in general practice has been associated with poorer care continuity (McNair et al. 2015), access to mental health services (McNair and Bush 2016) and psychosocial wellbeing (Durso and Meyer 2013). Yet an Australian study found that around half of LGBT people believed their GPs were unaware of their sexual orientation (McNair and Bush 2016). This has been attributed to pervasive misconceptions about the clinical relevance of sexual orientation within the medical profession and providers’ reluctance to discuss sexual orientation in consultations (McGlynn et al. 2020). Onus is instead placed on individuals receiving care to ‘come out’ within a health system that implicitly codes them as heterosexual (attracted to people of the ‘opposite’ gender) or monosexual (attracted to one gender, e.g. lesbian-identifying women) (Mulligan and Heath 2007; McNair et al. 2015; McGlynn et al. 2020; Kirubarajan et al. 2021).

Further impacts of health care’s erasure and stigmatisation of less visible sexual identities have been understood through bi+ and queer individuals’ accounts of their healthcare experiences. They have been found to face more discrimination in health care, are less likely to have a regular GP (McNair and Bush 2016; McNair et al. 2018; Grant et al. 2020) and report experiences of mental health issues at higher rates than lesbian-identifying women (McNair et al. 2011; McNair and Bush 2016). Many individuals in these particularly underserved groups report a preference for LGBTQA+ inclusivity, and the accessibility of these services may therefore be a necessary precursor of their engagement with health care. Access to these services is, however, complicated by geographical challenges, given they are inequitably distributed across the country (Grant et al. 2020; Cronin et al. 2021).

Providers working in services with a reputation for LGBTIQA+ inclusivity may further have limited capacity to adopt transformative care models (Uink et al. 2022); for example, to address patriarchal, racist, ableist and other discriminatory systems that historically underpin western medicine. There is recognition among people whose identities encompass multiple marginalised or stigmatised groups that an individual healthcare provider may not have capacity to respond to all of their identities and health concerns holistically (Robards et al. 2019; O’Shea et al. 2020; Newman et al. 2021). They may therefore choose to attend a range of services conducive to their needs at the time, rather than prioritising continuity of care with a single GP (Robards et al. 2019). This strategy may also protect multiple-marginalised people from the various forms of discrimination that can lead to foregone care (Robards et al. 2019).

Healthcare management is often a multidimensional task for individuals identifying with two or more marginalised or stigmatised groups, when these identity groupings have intrinsic, at times incongruent, value systems or healthcare-related needs (Robards et al. 2019; O’Shea et al. 2020; Newman et al. 2021). For example, LGBTQA+ people with a disability may need to educate providers and have limited opportunity to convey the full range and complexity of their identities, experiences and health concerns (O’Shea et al. 2020). Older LBQ+ women are often overlooked in efforts towards LGBTQA+ inclusive practice due to the culmination of patriarchal and ageist structural inequalities and provider biases (Hayman and Wilkes 2016). Race/ethnicity, immigration status, education level and parenting are further experiences found to be associated with lesbian-identifying women’s sexuality nondisclosure in health care (Durso and Meyer 2013).

While previous studies have linked GP care engagement with mental health outcomes and service access (McDermott et al. 2018; Grant et al. 2020; Carpenter 2021; Cronin et al. 2021), few have identified how identity-affirming GP practices can shape LBQ+ women’s access to LGBTIQA+ inclusive mental health care. The participant sample for this study was drawn from a national survey of 6835 LGBTQA+ people aged 18+ years in Australia. Cautious about limiting inclusion to cisgender women when discrimination within and beyond health care contributes to particularly heightened health inequalities for trans and gender diverse people, we understand challenges to healthcare engagement among these populations are likely to be distinct (Strauss et al. 2020), and need to be the subject of specific attention in future research. Additionally, the findings of this study were not intended to reduce participants’ realities according to the discrete demographic categories used; rather, highlight the importance of identity-affirming GP practices in LBQ+ women’s mental healthcare engagement, together with inequities that require addressing to improve the health and wellbeing of this population. The two key aims were to identify:

Method

Results

Discussion

LBQ+ cisgender women were more likely to report engaging with mental health care in the previous 12 months if they had a regular GP, and inclusive or specific LGBTIQA+ mental health services were accessed primarily by women whose regular GPs knew about their sexual orientation. Discrepancies in identity disclosure for specific sub-populations are particularly noteworthy, given that non-disclosure appears to compromise access to LGBTIQA+ inclusive services, potentially when these services may be preferred. In context with prior documentation of the extent of LBQ+ cisgender women’s unmet mental health needs, together with studies linking sexual identity disclosure in general practice with continuity and satisfaction with general practice care and ‘met’ mental health needs (McNair et al. 2011, 2018), GPs are likely missing opportunities to develop trusting relationships with LBQ+ cisgender women through which they may facilitate continuity of care and access to appropriate forms of mental health support.

The two-thirds of participants reporting they had a regular GP is a relatively low proportion compared to studies of the general population. One such study showed that about 80% of adults had a regular GP (Wright et al. 2013). Odds of having a regular GP were lowest among women aged <25 years. Compared to older generations, young LGBTQA+ people express a greater desire for clinicians who show ‘immediate and visible forms of acceptance,’ and are willing to seek new providers when existing ones don’t meet these expectations (Newman et al. 2021). It appears that non-inclusive practices may interact with age-related structural barriers to consistent GP care and heighten young LBQ+ women’s barriers to mental health care. Potentially by virtue of these practices, young LBQ+ women’s mental health needs may be particularly underserved relative to the general population, given that people aged 18–25 years in Australia have been shown in population-level data to be the most likely of all age cohorts to access subsidised mental health care (Australian Institute of Health and Welfare 2019).

LBQ+ cisgender women with a disability were more likely to have a regular GP, which has also been shown in general population data (Department of Social Services; Melbourne Institute of Applied Economic and Social Research 2019). Women with disability were however no more likely than other participants to believe their GP was aware of their sexual orientation. LGBTQA+ people with a disability have reported challenges with sexual identity disclosure in health care including provider assumptions of heterosexuality or asexuality, gatekeeping of health care by carers and relatives and lack of disability inclusion within LGBTIQA+ spaces (O’Shea et al. 2020). In the context of higher rates of mental health concerns among this population (Hill et al. 2022), a better understanding of their experiences when accessing inclusive LGBTIQA+ mental health services, and the role of GPs in facilitating access, is needed. It could be argued that disclosure and sensitive referral to inclusive LGBTIQA+ mental health services are even more important for this sub-group, given their multiple marginalised identities and barriers to peer and social support.

Less than one-third of LBQ+ cisgender women who had accessed mental health care had done so via LGBTIQA+ inclusive or specific services, with greater odds observed among participants whose regular GPs were aware of their sexuality. These participants were typically older, highly educated, on high incomes, lesbian-identifying and living in inner suburban or rural areas. Previous research strongly indicates non-disclosure may be a consequence of inadequately inclusive GP practices such that LBQ+ cisgender women do not feel comfortable or safe disclosing their sexual orientation (Mulligan and Heath 2007; Durso and Meyer 2013; Newman et al. 2021; Carpenter 2021). Pansexual and queer identifying people in particular are more likely to prefer inclusive over mainstream health services and to report greater reluctance to access mental health care than other sexual minority groups (McNair and Bush 2016; McNair et al. 2018; Grant et al. 2020). This makes identity-affirming GP relationships pertinent to addressing their mental health needs.

Lower rates of sexuality disclosure to GPs in regional and outer-suburban areas may be due to heightened anticipation of discrimination; for example, it has been found that social attitudes towards LGBTIQA+ people may be more negative in outer-suburban compared to inner-suburban areas of capital cities (Flood and Hamilton 2005). Women living regionally have, however, been found to value and make decisions about health care based primarily on interpersonal rapport with their providers (Ward et al. 2015). The lower rates of GP awareness of sexuality among regional participants, but not of having a regular GP, demonstrates a dynamic and non-mutually exclusive relationship between satisfaction with GP care and sexuality nondisclosure. The co-existence of these seemingly discordant factors may occur when one’s minoritised sexuality is not a key facet of their holistic sense of identity (McNair et al. 2012; Grant and Nash 2020).

While rural LGBTQA+ people also report more barriers and discrimination in health care than their urban counterparts (Nic Giolla Easpaig et al. 2022), the emergence of rural queer hubs – offering the social networks, inclusive services and broader awareness and visibility of queer community – could explain the similar rates of sexuality disclosure among inner-suburban and rural participants. The counter-urban movement and cultural consumption practices of predominantly white, middle-class lesbian and gay cisgender women and men have been simultaneously implicated in the urbanisation and gentrification of rural areas (Smith and Holt 2005). These ‘gay capitals’ are inhabited primarily by elder lesbians and potentially less accessible or catered to young people who are more likely to inhabit plurisexual identities and have considerably less financial security (Grant 2021). Taken together, our findings challenge contested notions of inherent non-inclusion in rural and regional areas but infer potential inequities in access to inclusive GP care and mental health services across identity groupings (e.g. according to age, sexual orientation and class), within and between urban and non-urban communities. This demonstrates the importance of identifying geographically specific research and healthcare priorities.

The findings provide valuable insight into GP care engagement and mental health service access among a large sample of LBQ+ cisgender women. There are, however, some limiting factors. The sample was not nationally representative, and therefore has limited generalisability to specific identity groups. For example, there was no difference in regular GP status and GPs’ sexuality awareness according to country of birth, potentially due to the small sample of non-Australian-born participants. Pre- and-post-migration experiences, structural violence and explicit forms of discrimination and abuse (e.g. based on racial, patriarchal and homophobic constructs) in countries of origin and settlement have been found to exacerbate health inequalities for women and LGBTQA+ people (Namer and Razum 2018; Sullivan et al. 2020), while a person’s visa status in Australia can further limit access to health care. We also recognise that collapsing sexual (and other) identities into discrete categories may erase their hybridity and the range of terms people use to describe their realities. Exploratory research with LGBTIQA+ people, that centres their realities and offers deeper insight into affirming healthcare relationships and mental health management within and beyond health services, is needed.

Conclusion

Honest, open dialogue about sexuality in general practice settings appears to be a necessary precursor to accurate clinical assessment and linkage to mental health services for LBQ+ cisgender women. However, heterosexism and monosexism in primary care are likely reducing their access to mental health services; particularly to LGBTIQA+ inclusive services when these may be preferred. Barriers to identity-affirming GP and mental health services need to be addressed particularly for young LBQ+ cisgender women, those who identify as bi+ or queer, have below undergraduate-level education, lower incomes, or live in outer-suburban or regional areas. GPs need to work to improve their competency in LGBTIQA+ inclusive practice, incorporate sexual orientation in holistic healthcare management, develop trust and rapport with patients and ensure general practice environments are safe and affirming places for people to comfortably discuss their sexuality when it is relevant to their health care. Rather than eliciting unwanted disclosure, GPs referring to specialist mental health services may consider it appropriate to ask patients whether LGBTIQA+ inclusivity is important to them.

Data availability

The data that support this study will be shared upon reasonable request to the corresponding author.

Conflicts of interest

The authors declare no conflicts of interest.

Declaration of funding

This study was funded by the Australian Lesbian Medical Association, while the Private Lives 3 study, from which these data are drawn, was funded by the Victorian Government Department of Health and Human Services and the Department of Premier and Cabinet.