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COLUMBIA SOCIAL WORK REVIEW, VOL. IX | 1 

LESBIAN, GAY, BISEXUAL, TRANSGENDER, QUEER, 
ASEXUAL, INTERSEX ET AL. (LGBTQAI+) HEALTH 
ACCESS DISPARITIES IN FEMALE-IDENTIFIED 
CLIENTS

JENNIFER HAND

Though they recently received legal legitimacy, the LGBTQAI+ community 
faces discrimination through deeply entrenched heterosexist social systems, 
which amplify inequities for women and gender minorities. Social workers 
must advocate for expansive policy interventions to promote economic and 
health equity for female-identified members of the LGBTQAI+ community. 
Practical policy interventions for the promotion of health equity include 
provider training programs, anti-discrimination protections, the collection 
of comprehensive demographic data, and youth education curricula. 

INTRODUCTION: CODIFYING BASIC RIGHTS
To address lesbian, gay, bisexual, transgender, queer, asexual, intersex 

et al. (LGBTQAI+) health policy, we must consider the historical context 
of the population in the United States.1 Within the last twenty years, the 
legal system codified basic safety and fundamental rights for LGBTQAI+ 
citizens. The legal system makes change slower than most other systems 
in order to preserve the rule of law from the tidal waves of popular opinion, 
and law often follows and codifies established policy. In the United States, 
there is great discrepancy in social attitudes towards this community that 
the creation of anti-discrimination laws beget new policies across all areas 
of social systems (Harrison & Michelson, 2017). Consequently, new anti-
discrimination laws prescribe the conscientious and meticulous undoing 
of systemic bias in all of our social services, from housing to health care. 

According to Martos, Wilson, & Meyer (2017), LGBTQAI+ health care 
was born out of self-advocacy and self-determination from the beginning. 
In the mid-20th century, underground LGBTQAI+ activism groups began 
emerging, effectively birthing identity politics for the community (Martos 
et al., 2017). After the Compton’s Cafeteria Riot in San Francisco in 1966 
and the more widely known Stonewall Riot in 1969, during which the police 
raided queer spaces to humiliate and criminalize the community, organizers 

1 Until Obergefell v. Hodges (2015), the community was denied the right to marriage. This 
decision is significant in that the right to marriage is not the right to love unencumbered, but 
the right to retain financial and other benefits through the formation of a legally recognized 
partnership. Until Lawrence v. Texas (2003), the United States criminalized sex acts between 
two consenting adults. Again, this case illuminated the legal discrimination against a 
marginalized group and attempted to protect the community from government intrusion into 
personal affairs. Lastly, Romer v. Evans (1996) was the first federal case law protecting the 
LGBTQAI+ community from state-sanctioned “bare animus”—the intent to harm a politically 
unpopular group.



2 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

JENNIFER HAND

mobilized to carve out intentional queer spaces including community-based 
health organizations—in urban centers around the country. 

Following these advocacy efforts and 
the removal of homosexuality from the 
DSM in 1973, care centers focused on 
LGBTQAI+ health emerged en masse in the 
1970s (Martos et al., 2017).2 Due to rampant 
homophobia and transphobia among 
the medical and other care professions, 
the standard of care for LGBTQAI+ 
individuals was low, to the point where 
individuals would not feel comfortable 
disclosing lifestyle and health habits to 
providers for fear of discrimination. As a 
person’s lifestyle intersects very closely 
with his or her health care provision and 
health outcomes, this is an unacceptable discrepancy. This hesitancy to 
discuss care with providers due to stigmatization—and thus harm reduction 
practices—may indeed be a key reason the HIV epidemic decimated this 
population in the 1980s and 1990s (King, 2011).3 

Nearly fifty years after the riots sparking organizing efforts, and about 
twenty years after the initial case law identified them as an “unpopular 
political group” (Romer v. Evans, 1996), the LGBTQAI+ community 
continues to work aggressively towards undoing homophobia, transphobia, 
biphobia, heterosexism, and sexism in every area of social services. As 
LGBTQAI+ service provision is still an emerging area of law, policy, and 
health care for a high needs population, service delivery has much room for 
improvement  (Martos et al., 2017). 

LGBTQAI+ DISPARITIES IN HEALTH ACCESS
As heterosexism, homophobia, transphobia, biphobia, and misogyny 

become less overtly enacted on LGBTQAI+ identified individuals due 
to statutory intervention,4 members of the community still experience 

2 At the same time, Gender Identity Disorder was codified in the DSM and opened the 
transgender community up to discriminatory medical practices (Martos et al.). 
 
3 Discussion of the HIV epidemic and its impact on LGBTQAI+ health policy with due 
diligence would require more words than permitted by this submission and is not entirely 
germane to the subject matter of SMW health disparities.

4 On September 29, 2017, the United States voted against a ban on the death penalty for same-
sex relations at a United Nations conference. Similarly, the United States Department of 
Justice filed an amicus brief—legal support which may influence case law—for Masterpiece 
Cakeshop v. Civil Rights Commission on September 6, 2017. This case is before the Supreme 
Court of the United States regarding the tension between first amendment rights of business 
owners and legal discrimination against the LGBTQAI+ community in the contracting of 

“Due to rampant 
homophobia and 
transphobia among 
the medical and other 
care professions, the 
standard of care for 
LGBTQAI+ individuals 
was low, to the point 
where individuals 
would not feel 
comfortable disclosing 
lifestyle and health 
habits to providers for 
fear of discrimination.”



COLUMBIA SOCIAL WORK REVIEW, VOL. IX | 3 

LGBTQAI+ HEALTH ACCESS DISPARITIES IN FEMALE-IDENTIFIED CLIENTS

structural inequities, which may limit their quality of life and cause 
long-term damage to their well-being (Eckstrand, Lunn, & Yehia, 2017). 
LGBTQAI+ populations experience higher barriers to healthcare than 
heterosexual populations (Eckstrand et al., 2017). The population also 
experiences an “increased incidence of sexually transmitted infections, 
mood and anxiety disorders, and intimate partner violence” as compared 
to heterosexual and cisgender populations and experiences poorer health 
outcomes across the lifespan (Lunn et al., 2017). 

Lunn (2017) estimates that 2.4% of the general population is 
LGBTQAI+ identified and represents a cross-section of the general 
population. Though already disadvantaged, the community—due to its 
diversity across age, gender, socioeconomic status, ethnicity, and race—
reflects the systemic inequities prevalent in the greater population 
(Krehely, 2009). Minority stress, often linked to poor health outcomes due 
to internalization of isms and externalized discrimination, is intensely 
compressed in these populations (Mule et al., 2009). Notably, LGBTQAI+ 
individuals of color are simultaneously pathologized as disease-carriers 
yet denied access to health care, culturally competent representation, and 
care provision (Lassiter, 2017). For the purposes of this paper, I choose to 
isolate the social problem of LGBTQAI+ health access disparities to the 
intersection of gender and sexual minority status, which is simultaneously 
broad enough to produce illuminative disparities in the way marginalized 
communities gain access to health care, yet discrete enough to provide 
specific examples of how care is out of reach for the most vulnerable in 
ways that transcend racial and ethnic identity. 

STRUCTURAL ISSUES FOR SEXUAL MINORITY WOMEN

LGBTQAI+ individuals who are female-identified (sexual minority 
women, SMW) experience higher barriers to health care and poorer 
long-term health outcomes than their heterosexual or male counterparts 
across race, ethnicity, and ability (Lunn et al., 2017). SMW experience 
poorer long-term health outcomes and higher barriers to health care than 
male-identified members of the LGBTQAI+ community or cisgender 
heterosexual women (Eckstrand et al., 2017; Lunn et al., 2017). SMW 
are less likely than gay or bisexual men to have a primary care provider 
and health insurance (Lunn et al., 2017). SMW are more likely to have 
chronic health conditions, such as obesity or substance use disorder (Lunn 
et al., 2017). Additionally, SMW are less likely to enroll in traditional 

business services. Despite great strides for sexual and gender minority inclusivity under 
the Obama administration, homophobia and transphobia may be on the rise under this 
administration. For the purposes of this paper, I will operate under the assumption that 
society has made and is making great strides towards equity, which cannot be undone in a 
few, inelegant legal maneuvers. 



4 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

JENNIFER HAND

employment, requiring them to secure insurance outside of the workplace 
(Lunn et al., 2017; Eckstrand et al., 2017). Consequently, the population 
as a whole is not likely to be engaged in workplace diversity initiatives and 
wellness programs, which help moderate risk behaviors (Eckstrand et al., 
2017). SMW are also less likely to enroll in spousal health care due to lower 
rates of marriage among the population (Blosnich, 2017). 

 Even when SMW enroll in healthcare, they are less likely to 
experience quality of care and culturally-competent service provision 
(Blosnich, 2017). On the whole, SMW report lower satisfaction rates with 
primary care provision than their heterosexual or sexual minority male 
counterparts (Baldwin, Dodge, Schick, Sanders & Fortenberry, 2017). 
Lower satisfaction rates and lack of culturally competent service provision 
lead to difficulties in securing a continuum of care, which addresses chronic 
health issues and provides preventative care (Baldwin et al., 2017). Most 
indicative of structural inequity, the needs of SMW are not adequately 
reported or measured by researchers (Patterson et al., 2017). 

People with means have access to quality health care (Marmot, 
2005). In the United States, economic inequity rests at the heart of health 
care disparities (Fiscella & Williams, 2004). Women are economically 
disadvantaged as compared to men, after lower entry-level salaries 
and gross income disparities (Hegewisch & Williams-Baron, 2018; 
National Women’s Law Center, 2017; Kirkpatrick, 2018). And—even 
after Obergefell v. Hodges—sexual minorities are less likely to enjoy the 
stabilizing economic benefits of marriage, such as dual-income households, 
spousal health insurance, domestic workload sharing, or provision in the 
event of illness (Eckstrand et al., 2017). Despite reports suggesting that 
SMW receive an earnings premium compared to heterosexual women, 
SMW make less than men, so SMW couples experience a compounding 
of the gender wage gap (Alexander & Ravani, 2016; National Women’s 
Law Center, 2017). The earnings premium is marginal at best and does 
not undo the exorbitant gender wage gap. Indeed, poverty rates among 
female-identified same-sex couples are approximately eight percent, 
which is higher than poverty rates among heterosexual couples (S.K., 
2016). Lastly, workplace discrimination destabilizes job security and then 
disrupts health insurance and continuation of care (Badgett et al., 2007). 
Consequently, health insurance mandates such as those advocated by the 
Affordable Care Act represent the single greatest barrier removal to health 
access (Housel & Harvey, 2017). Though the health insurance mandate is 
a promising start, the disproportionately low rate of health access for this 
population necessitates additional protections across all practice areas, 
such as provider training for culturally competent care, the expansion of 
anti-discrimination provisions, government collection of demographic data to 
track and assess population health outcomes, and youth education curricula. 



COLUMBIA SOCIAL WORK REVIEW, VOL. IX | 5 

LGBTQAI+ HEALTH ACCESS DISPARITIES IN FEMALE-IDENTIFIED CLIENTS

INTERVENTIONS IN ADVOCACY AND TRAINING

LGBTQAI+ affirmative laws improve health outcomes because they 
legitimize individuals, improve societal attitudes, and—most importantly—
lessen minority stress (Buffie, 2011). Because the community has only 
recently been legitimized through legal avenues—and thus has only 
recently been identified as a valuable data point to track in health care—
there is a dearth of relevant research for interventions and health outcomes 
(Patterson et al., 2017).  

Policy interventions exist at various system intersections. Continued 
legal legitimacy is a necessity. In 2017, sexual orientation and gender 
identity are still not protected classes (Foti, 2017).5 Providing government 
oversight of discriminatory practices and establishing a department or 
team to oversee these rules of law would improve equity (Mule et al., 2009). 
Mandating sexual orientation and gender identity inclusion in research 
collection would generate the data necessary to provide adequate health 
care to these populations by observing trends and practice solutions 
(Patterson et al., 2017). Provider education including training providers on 
asking the right questions appropriately, and encouraging more LGBTQAI+ 
individuals to enter care services would ensure that practice is inclusive, 
accessible, sensitive, and equitable (Lassiter, 2017; Mule et al., 2009). In 
addition, creating programming that builds self-esteem, body autonomy, 
and self-advocacy skills—such as those taught in many youth programs and 
Gender and Sexualities Alliance groups—may improve health outcomes 
through the creation of self-advocates and conscious consumers of medical 
care (Poteat et al., 2013).

ANTI-DISCRIMINATION
PROTECTIONS AND DATA COLLECTION

Though the LGBTQAI+ community has still not achieved protected 
class status and there is much room for improvement, health policy has 
evolved to be more inclusive and sensitive to the specialized needs of the 
population. As funders and governments continue to promote evidence-
based practice (Durso, 2017), social workers must push for sound evaluative 
processes and data collection to provide visibility to the population and 
create policies that reflect the true landscape of the LGBTQAI+ client 
experience. 

We must continue to work towards macro-level policy changes at all 
levels of government, protecting the community from discrimination and 
wage disparity, and providing avenues for compliance and enforcement. 

5 The Equal Employment Opportunity Commission (n.d.) released an anti-discrimination 
doctrine for sexual orientation and gender identity, which provides supportive policy to 
stabilize the workforce for this population, and thus economic security and access to health 
care. 



6 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

JENNIFER HAND

To date, 47% of the LGBT population live in states that protect them 
from gender or sexual orientation discrimination in the workplace or in 
public accommodations (Movement Advancement Project, 2018). The 
establishment of localized LGBT government agencies—such as those 
developed in Philadelphia, D.C., and San Francisco—promotes civil rights 
policy, coordinates services across cities, develops infrastructure for 
culturally competent training, collects outcome data, and enforces high 
standards of service delivery (City of Philadelphia, 2018; DC Mayor’s 
Office, 2018; San Francisco Human Rights Commission, 2018). 

Similarly, the creation of an LGBTQAI+ serving bureau at the 
Department of Human Health Services (HSS) would serve as the 
appropriate tool for collecting data, enforcing policy, and making 
recommendations for future protections. In 2010, HSS recommended 
the collection of LGBT data collection through the Healthy People 2020 
initiative (HSS, 2018). While doing so is an adequate step, mandating data 
collection in medical, U.S. Census, and American Community Survey 
records would further legitimize the population and ensure that pertinent 
data points are studied and reviewed—a critical step because much of the 
current reporting on LGBTQAI+ health comes from provider conversations 
and anecdotal evidence (Durso, 2017). We cannot know the true disparity 
without concrete quantitative data to support qualitative research.

PROVIDING TRAINER PROGRAMS
LGBTQAI+ visibility in health care settings requires disclosure 

(Rondahl, Innala & Carlsson, 2006). SMW “look like everyone else...act like 
anyone else, and possess no identifiable or unique characteristic” (Willes & 
Allen, 2014). Disclosure of sexual identity or sexual practice is the gateway 
to informed care and selection of services (Smith & Turell, 2017). Sexual 
and romantic practice intertwine so closely with our physical and mental 
health that refusal to acknowledge them in health care is detrimental to the 
whole person approach to service delivery (Willes & Allen, 2014). 

And yet, the burden for quality care currently rests on the client’s self-
disclosure, self-advocacy, and protection of one’s own health information 
(Smith & Turell, 2017). Many providers do not ask their clients’ sexual 
orientation because they assume heterosexuality, feel uncomfortable 
including sexual orientation in the psychosocial model of care, or do not 
consider it necessary due to their heterosexist lens and a misunderstanding 
of their clients’ experiences (Rondahl et al., 2006; Talan et al., 2017; 
Spiekermeier, 2017). Worse yet, many SMW feel misunderstood or 
aggressed upon by their providers, or else forcibly outed, so much so that 
they do not want to engage in services again (Martos et al., 2017). This 
failure to deliver culturally competent, or even culturally aware, care by 
requiring clients to carry the burden of disclosure creates a fissure between 
the client and their care team, further exacerbating health disparities. 



COLUMBIA SOCIAL WORK REVIEW, VOL. IX | 7 

LGBTQAI+ HEALTH ACCESS DISPARITIES IN FEMALE-IDENTIFIED CLIENTS

Enacting direct service policies that standardize best practice would 
help interrupt health care disparities from the ground up (Spiekermeier, 
2017). As with all high-needs populations, 
a solution can revolve around investment 
in standardization of services, creation 
of treatment plans for specific needs, and 
empathic communication of care (Mehta, 
2017; Spiekermeier, 2017; Eckstrand et al., 
2017). Training providers on best practice, 
continuing professional education, and 
implementing standardized protocols 
would serve as a mezzo-level intervention 
for the protection of the community in 
direct practice (Spiekermeier, 2017). 
Service models that privilege flat affect, 
open-ended questions, non-judgmental questioning, and requesting 
permission in the delivery of care may yield the best results (Eckstrand et 
al., 2017; Mehta, 2017). 

YOUTH HEALTH EDUCATION CURRICULA
Lastly, in micro practice, social workers can promote early intervention 

by engaging youth in appropriate health education (Poteat et al., 2013). 
Young people who are more informed about their bodies and health 
outcomes tend to adopt healthier lifestyles (Da Silva Vilelas Janeiro et al., 
2013). Affirmative health curricula teaching bodily autonomy build self-
esteem and respect for persons, and prime participants to be conscious 
consumers of medical care (Keuroghlian et al., 2017). For children, this 
type of intervention can result in self-sufficiency and self-determination, 
and act as a protective factor over the lifespan. 

Family is the first point of contact for youth in providing vocabulary 
and understanding body function and expression. Additionally, family 
members may act as gatekeepers to health services for youth. This 
dynamic may present a barrier for LGBTQAI+ identified youth who need 
to rely on their families for determination and care, which may be at odds 
with the youth’s identity, expression, or behavior. Consequently, youth 
health education incorporating gender and sexual orientation may further 
legitimize identity and promote clarity for youth (Keuroghlian et al., 2017).

CONCLUSION
Equity rests at the heart of social work practice (National Association 

of Social Workers, 2017). Equity requires the fair distribution of services 
and resources, especially in a health setting (Omrani-Khoo et al., 2013). 
Although the concept of fairness is subjective, the modern understanding 

“...a solution can 
revolve around 
investment in 
standardization of 
services, creation 
of treatment plans 
for specific needs, 
and empathic 
communication of 
care (Mehta, 2017; 
Spiekermeier, 2017; 
Eckstrand et al., 2017).” 



8 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

JENNIFER HAND

of equity means that we push services and resources towards those who 
need it most to maintain average—if not 
basic—access to social and economic 
survival. When working with people 
and communities that have been 
greatly disenfranchised, social workers 
are required by the Code of Ethics to 
consider the intersectional identities 
and experiences that restrict access to 
resources (National Association of Social 
Workers, 2017). Though the LGBTQAI+ 
community has been greatly disenfranchised, and is only just receiving 
the legal protection it deserves, cis and trans women in the community 
experience enormous inequity in the provision and distribution of social 
services, health care, and employment. We must consistently provide 
interventions at the macro, mezzo, and micro levels to promote economic 
and health parity for female-identified members of the LGBTQAI+ 
community.

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“We must consistently 
provide interventions 
at the macro, mezzo, 
and micro levels to 
promote economic 
and health parity for 
female-identified 
members of the 
LGBTQAI+ community.”



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JENNIFER HAND, located in San Francisco, is a Masters of Science in 
Social Work candidate in the Social Enterprise Administration program at 
Columbia University’s School of Social Work. The SEA program provides 
training across all three levels of social work practice, with emphasis on 
management and policy. Her Field of Practice is health, mental health, and 
disability. For her second-year placement, Jennifer works at the Mayor’s 
Office of Economic and Workforce Development where she researches 
and assesses programs to promote equity and improve data collection. 
Additionally, Jennifer works as a gender and sexuality health educator 
and chairs the LGBTQ Community Services and Education Committee 
at the San Francisco Planning Department. Prior to attending Columbia 
University, she worked in the legal industry, small business management, 
and created a workforce navigator model for professionals managing 
severe mental illness. She attended Stony Brook University in New York 
for her B.A. in English and Education.


