“ vertheyears,society,familyandwork O havecausedinternalhomophobiathatI dealwithallthetime.Thefearofbeing treatedpoorlybecauseIamlesbianis alwayspresent.

” “havehadacardiologisttellmehedidnot I approveofme,mypartner,orourlifestylebut hewouldstilltreatme.Needlesstosay,Ididnot feelveryconfidentinhiscareandfoundanew doctorassoonasIcould.”

Lgbt heaLth and human SeRviceS needS in new yoRk State

“feelpeopleinmyneighborhoodneedgreateraccesstoquality,affordablehealthcare.Often,LGBTaccess I tohealthcarehasnothingtodowithqueerspecificissues,butratherwithhowwearetreatedduringroutine medicalexaminations.Havingwell-informedandsensitivestaffwouldprobablyhelpotherminoritieswith highincidencesofviolenceorthreat,suchasimmigrants.”

“ ’vefoundtheexperienceoflookingatschoolsformychildrentobesimilartothe‘comingout’processofmy I youth.Schoolsandchildren’sorganizedactivitiesstilldonothaveauniformapproachto‘alternativefamilies.’ Greatereducationoftheprofessionalsinthesearenaswouldbehelpful.Wehaveconsistentlygoneintothe classroomtoexposetheotherchildrentoourfamilyinanefforttonothaveourchildrenbeputinthepositionof explainingordefendingourfamily.”

“ ’madeafperson,andIamagayman.Iliveinagreatcommunity,buttherearesomepeoplewhoarestill I uneducatedaboutdeafcultureanddeafpeople’sneeds.WhenIrequesttohaveaninterpreter,somehealth professionalsassumeanattitudeof,‘Thisguyisdeafandcan’tspeak.HowdoIcommunicate?’Ifindthis attitudetoberidiculousontheirparts,becauseIknowhowtoassertmyselfandrequestaninterpreter.”

“haveapartnerwhohasagoodjobwithhealthinsurance,andyetIamon I Medicaidbecausehisjobwon'tgivemebenefits.Ihaveaseriouschronicillness andcan'tworksoIneedmyMedicaid.Ifwehadlegalmarriage,Iwouldnot needtousepublicassistancetomeetmyhealthcareneeds.”

“ ypartnerisatranspersonwhoismaletofemale.Wehaveencounteredalotofissuesrelatedto M transcare.Thelargestissuebeingtheabilityforinsurancecompaniestodenyhealthservicestoa transpersoniftheservicesarethoughtofasfemaleservices,suchasgynecological,uterine,breast andovariancancercare.”

“nallofmylife,therehasbeenonlyoneprofessionalhealthcareofficethathasan I in-takeformthatincludes‘partnered’forLGBTdesignation.Ibelievethatmedical officesshouldbeexplicitaboutsupportingpartnersinrelationtolovedones.No oneunderstandstheisolationandfearsitcauseswhentheydon’t.”

“ yconstantconcernishowmypartnerandIcanhavechildrenandhaveoneofustakeevenasmall M amountoftimeoffworktocareforthemwhilestillkeepingusallinsuredwithhealthcoverage.This wouldbeaHUGEadvantageofmarriage.Evenifwedon’thavechildren,itwouldbeabigloadoffmy mindtoknowthatIcouldinsureher(orherinsureme)ifsheeverwantedorneededtostopworkingfor anyreason.”

“ omenneedspecializedsexeducation W aimedatwomenwhohavesexwith womenthatisnotcondom-based.”

RepoRt pRepaRed by Somjen FRazeR FoR the empiRe State pRide agenda Foundation and the new yoRk State LeSbian, gay, biSexuaL and tRanSgendeR heaLth and human SeRviceS netwoRk

Contents
executive Summary introduction methodology Lgbt population Size and demographics Population-basedEstimatesofLGBTDemographics LGBTDemographicsintheNeedsAssessmentSurvey Findings InsuranceandSourcesofHealthcare BarrierstoHealthcareAccess GeographyandTransportation MentalIllnessandAccesstoMentalHealthcare SubstanceAbuse Housing SocialSupportandSocialIsolation Violence SpecificPopulations  TransgenderandGenderNon-conformingPeople  PeopleofColor  Youth  Seniors  Families next Steps works cited acknowledgements 1 2 3 4 4 4 6 6 6 7 8 9 10 10 11 12 12 13 14 15 16 17 19 19

Thequotesonthefrontandbackcoverofthisdocumentarefrom NeedsAssessmentsurveyrespondents’answerstothequestion ‘WhatisthemostpressinghealthandhumanserviceneedforLGBT peopleinNewYorkState?’Thequoteshavebeenlightlyeditedfor grammar,confidentialityanddesign.

1

ExecutiveSummary

T

hisassessmentofLGBTHealthandHuman ServiceNeedsinNewYorkState(“theNeeds Assessment”)wasdesignedtoexamineexisting datasources,identifygapsindataandcollectoriginal datainordertoestablishthemostpressingneeds andgapsforlesbian,gay,bisexualandtransgender (LGBT)non-HIVhealthandhumanservicesinNew YorkState.Tothatend,NewYorkStateDepartmentof HealthandNewYorkCityDepartmentofHealthand MentalHygienesurveyswereanalyzed,60experts inLGBThealthandhumanserviceswereinterviewed (individuallyoringroups)andnearly3,500LGBT peopletookanonlineorpapersurveyabouttheir healthandhumanserviceneeds. Herearesomekeyfindings: •• About4.1%ofthegeneralpopulationself-identifies aslesbian,gayorbisexualongovernment-funded, population-basedsurveys.Lessisknownabout transgenderidentity;however,onesurveyestimates about300,000self-identifiedtransgenderpeoplelive inNewYorkState. •• Lesbian,gay,bisexualandtransgender(LGBT)people havepooraccesstohealthcarebecauseoflower ratesofinsuranceandutilizationofprimarycare.For example,theNewYorkCityDepartmentofHealthand MentalHygiene’sCommunityHealthSurvey(2007) estimatesthat20.6%oflesbianandgayand23.5% ofbisexualpeoplelackinsurance,whileonly14.9%of heterosexualpeopledo. •• Lackofculturallycompetentprovidersisamajor barriertohealthcareforLGBTpeople,withnearly 40%ofpeopleintheNeedsAssessmentsurvey sayingtherewerenotenoughhealthprofessionals whoareadequatelytrainedandcompetenttodeliver healthcaretoLGBTpeople.Geographicisolationis alsosignificantbarriertohealthcareforLGBTpeople livingoutsidemajorurbanareas. •• LGBTpeoplefacehomophobiaandtransphobiain theireverydaylives,andaremorelikelytoexperience depressionandlackofaccesstoadequatemental healthcare.Youth,transgenderandgendernonconformingpeopleandBlackandHispanicLGBT peoplewerethemorelikelytobedepressedandless likelytohaveadequateaccesstomentalhealthcare.

•• Homelessnessandinadequatehousingaresignificant barrierstohealthandwelfareforLGBTpeople. Nearly14%ofrespondentswerecurrentlyorformerly homeless. •• Lonelinessandsocialisolationwereparticular problemsforLGBTpeoplewhodidnotliveorwork inManhattan.Socialisolationhasnegativehealth outcomes,andthosewhoattendedeventsatLGBT centerswerelesslikelytobelonely. •• HateviolenceisanimportantproblemintheLGBT community,with13%reportingtheyhadexperienced anti-LGBTsexualassaultorviolenceseriousenoughto sendthemtothehospital. •• Transgenderandgendernon-conformingpeople aremorelikelytoexperiencebarrierstohealthcare, homelessness,violenceandothernegativehealth outcomes. •• Peopleofcolorneedculturallysensitiveservices bothwithintheLGBTcommunityandinmainstream settings.Theyreportedlowerincomes,morebarriers tohealthcareandmoredepressionandlonelinessthan whitepeople. •• LGBTyoutharemorelikelythannon-LGBTyouth toexperiencenegativehealthoutcomessuchas smoking,substanceabuse,violenceandriskbehavior, aswellassuicide. •• ManyLGBTseniorsareresilient,whileothersareat riskforsocialisolation.LGBTseniorsareparticularly vulnerabletofinancialexploitationandneglect. •• LGBTpeoplebuildfamiliesinavarietyofways,and thesefamiliesneedsupportandrecognition.

2

Introduction

T

hisdocumentreportsthefindingsofthefirst statewideLGBTHealthandHumanServices NeedsAssessmentinNewYorkState.Aneeds assessmentisaresearchprocessthatidentifiesthegaps anddisparitiesforaspecificpopulation,inthiscase, lesbian,gay,bisexualandtransgender(LGBT)people. Needsassessmentsarehelpfulintargetingprograms andfundingtotheareasofgreatestneed,aswellas understandingthesizeandcharacterofthegapbetween theneedsoftheLGBTpopulationandthoseofnon-LGBT people.Thereisaseriouslackofdataonthispopulation, andthisneedsassessmentaimstobegintofillthatgap. TheNeedsAssessmentwasfundedbytheNewYork StateDepartmentofHealth.TheEmpireStatePride AgendaFoundationcontractedthereporttoan independentconsultant. TheEmpireStatePrideAgendaFoundationisthe non-partisan501(c)(3)research,educationand advocacyorganizationaffiliatedwiththeEmpire StatePrideAgenda,Inc.,NewYork’sstatewidecivil rightsorganizationcommittedtoachievingfull equalityandjusticeforlesbian,gay,bisexualand transgender(LGBT)NewYorkersandourfamilies. ThePrideAgendaFoundationsupportsandadministers theNewYorkStateLesbian,Gay,Bisexualand TransgenderHealthandHumanServicesNetwork (theNetwork),acoalitionofoverfiftyLGBTspecificandLGBT-supportivenonprofitgroupsand organizationsthatprovidenon-HIVhealthandsocial servicestoLGBTNewYorkersandtheirfamilies. AlthoughtheNeedsAssessmentwascreatedin closecollaborationwiththeNetworkandthePride AgendaFoundation,thefindingsandconclusionsin thisdocumentaresolelythoseoftheconsultant.

Human services,forthepurposesofthis report,areanythingthatenhanceshealthor welfarethatisdeliveredbyaprofessional. Lesbian and gay peoplearepeoplewhoareromantically and/orsexuallyattractedtoand/orsexuallyactivewith peopleofthesamegender.Bisexualpeopleareattracted toand/orsexuallyactivewithpeopleofbothgenders.1 Sexual orientationgenerallyreferstopeople’ssexual identity,behaviororattraction.Sexualorientation wasrecognizedthroughself-identificationinthe NeedsAssessmentsurveyand,unlessotherwise noted,intheotherdatasourcesaswell. Transgenderisawordcommonlyusedtodescribe peoplewholiveinagenderdifferentfromtheone assignedtothematbirth.Peopleoftenusethisword todescribenotonlypeoplewhohavechangedtheir genderthroughsurgeryorcross-genderhormone therapy,butalsopeoplewhohavenon-medical gendertransitionsoridentifyastransgenderbutdo notseektochangetheirgenderlegallyormedically. Gender non-conforming peoplearepeoplewho expresstheirgendersdifferentlyfromsociety’s expectations,reject’male’and‘female’astheonly genderpossibilities,and/orblendgenders.Gender non-conformingpeopleintheNeedsAssessment surveyidentifiedtheirgendersinavarietyofways. Inadditionto‘gendernon-conforming,’theyalso identifiedas‘genderqueer,’‘genderblending’and ‘genderbending,’aswellasinavarietyofotherways. Homophobiareferstohatredorfearoflesbian, gayorbisexualpeople.Transphobiarefersto hatredorfearoftransgenderpeople.

3

Methodology

T

hisreportengagesfourpre-existing,populationbased,publically-availabledatasourcesandtwo sourcesoforiginaldata.2Inaddition,dataare contextualizedbyscholarlyliteraturewhereitisavailable. ExistingdatasourcesincludedthestatewideNYS DepartmentofHealthAdultTobaccoSurvey(ATS)from 2004,whichincludedquestionsonsexualorientation andgenderidentity,aswellastobaccouseandinsurance status.TwosourcesofNYCDepartmentofHealthand MentalHygieneNewYorkCity-specificdatawerealso used,includingtheNYCCommunityHealthSurvey(CHS) ofadultsandtheYouthRiskBehaviorSurvey(YRBS)of highschoolstudents.Botharefrom2007.3TheCHSand YRBSbothcollectdatanotonlyonsexualorientation, butalsoontheriskbehaviors,healthstatus,insurance statusandotherhealthinformationofrespondents. Neithercollectsinformationontransgenderidentity. Althoughthesedatasourcesincludeimportant informationaboutthehealthstatusandriskfactorsof LGBTpeople,furtherdatafocusedonLGBT-specific issueswerealsoneededinordertocompletetheNeeds Assessment.Tothatend,twostagesoforiginaldata collectionwereconducted.First,tenfocusgroupsand twoindividualinterviewswereconductedwith60key informantswhohaveparticularexpertiseinLGBThealth andhumanservicesfromthroughoutthestateofNew York.Thefocusgroupsandinterviewsdiscussedawide rangeofhealthandhumanserviceneeds,withparticular attentiontoprimarycare,mentalhealthandcounseling, substanceabuse,socialsupportandsocialisolation, criminaljusticeissuesandspecificpopulationssuchas youth,peopleofcolor,transgenderpeopleandseniors. Thereweresixgeneralfocusgroups,andonefocus groupeachonthefollowingtopics:youth,substance abuse,seniorsandpeopleofcolor.

Finally,3,772LGBTpeopletookanonlineandpaper surveyofhealthandhumanserviceneeds,conducted fromApril6-22,2009withafinalsampleof3,441 people.4ThesurveywasdistributedtoLGBTpeople throughoutNewYorkState,usingtheLGBTHealthand HumanServicesNetworkandrecruitingonlineaswell asin-person.Itincludeddemographicquestionsaswell assectionsonhealthcareaccess,violence,healthand humanserviceneeds,mentalhealthandbarrierstocare.

4

LGBTPopulationSizeandDemographics
POPULATION-BASEDESTIMATES OFLGBTDEMOGRAPHICS Lgbt people of color in the needs assessment Survey
10% 8.9% 8% 6.5% 6% 4.2% 2.7% 2% 0.8% 0% American Indian Arab or Arab American Asian or Black or Latino or Asian African Hispanic American American Mixed Race Other 0.7% 9.5%

E

stimatesofthesizeoftheLGBTpopulationin NewYorkStatevary.In2004,theNewYork StateDepartmentofHealth’sAdultTobacco Surveyincludedquestionsonsexualorientationand genderidentity.Itsuggestedthat2.6%ofadultsinNew YorkStatearelesbian,gayorbisexual,while2.1%are transgender.In2007,theNewYorkCityDepartment ofHealthandMentalHygiene’sCommunityHealth Surveyestimatedthat4.1%ofpeopleinNewYork Cityidentifyaslesbian,gayorbisexual;however,this surveydidnotaskabouttransgenderidentities. Nationalestimatessuggestthat4.1%ofthepopulation identifiesaslesbian,gayorbisexual(Mosheretal.,2005). However,alargernumberhavehadsexwithsomeone ofthesamegenderorexperiencesame-sexattractions. Forexample,onestudyfoundthat7%ofmalesand14% offemalesreportedsomeattractiontothesamesex.5

4%

Sexual orientation in the needs assessment Survey

50%

48.4%

40%

LGBTDEMOGRAPHICSINTHE NEEDSASSESSMENTSURVEY TheNeedsAssessmentsurveysamplewasdiverse comparedtoprevioussamplesoftheLGBTcommunity, whichtendtobewhiteandurban(Mayeretal., 2008).Atotalof8.9%ofrespondentsidentifiedas BlackorAfricanAmericanand9.5%identifiedas LatinoorHispanic;80.5%identifiedaswhite.Please notethatpeopleinthissurveycouldbemixedrace andcouldbeHispanicornon-Hispanicinaddition toselectingarace.Becauserespondentscould selectmorethanoneraceorethniccategory,the racialandethniccategoriesdonotsumto100%.
30%

36.0%

20% 12.9% 10%

17.0%

0% Gay Lesbian Bisexual Queer

1.4% all other

Amongsurveyrespondents,46.4%identifiedas female,45.7%identifiedasmaleand8.0%identifiedas transgenderorgendernon-conforming.6Maleandfemale refertorespondentswhoonlyselectedmaleorfemale, whilesometransgenderorgendernon-conforming respondentsmightalsohavebeenmaleorfemale. Theaverageageofrespondentswas41,withmost respondentsinthe25-44yearoldcategory(44.1%) and21.1%inthe45-54agecategory.Inaddition, 13.2%wereyouth(18-24)and21.5%wereover55. Forsomeofthedemographicquestions,including raceandsexualorientation,respondentscouldcheck allthatapply.Resultsmaynotsumto100%.

5

A total of 11.9% of the survey respondents were in poverty, having no income or household income below $10,000.
PeopleintheNeedsAssessmentsurveywerepartnered inavarietyofways,with41.4%sayingthattheywere notpartnered,53.7%reportingbeingpartneredwith ormarriedtosomeoneofthesamegenderand4.9% partneredwithormarriedtosomeoneofadifferent gender.7Overall,12.9%hadchildrenlivingwiththem. Atotalof11.9%ofthesurveyrespondentswerein poverty,havingnoincomeorhouseholdincome below$10,000.However,highincomepeoplewere alsorepresented,with20.8%oftherespondents havingahouseholdincomeabove$100,000. Overall,19.5%saidthattheydidnothaveenough incometomeettheirbasicneeds,while40.0%had justenoughand40.5%hadmorethanenough. Regardingemploymentstatus,18.3%ofthe respondentswerestudents.57.7%wereemployed fulltimeand12.8%workedparttime(respondents couldbeemployedandastudent).Inaddition,13.5% saidtheywereneitheremployednorastudent. Therewasgeographicdiversityinthegroupofpeople whorespondedtotheNeedsAssessmentsurveyas well.Lessthanhalf(49.9%)saidthattheylivedinlarge urbanareas;forexample,37.9%,ofthesamplelivedor workedinManhattan.Therewere18.4%livinginmidsizedcities,17.6.%livinginsuburbsand7.1%livingin smalltowns,while6.1%saidtheylivedinruralareas.

geographic diversity among needs assessment Survey Respondents
49.9% 50%

40% 30% 18.4% 17.6%

20%

10%

7.9% 6.1%

0% Large urban Midsize city Small city or town Suburban Rural

Lgbt people’s Responses to ‘i am ‘out’ to my family, friends or healthcare providers’ in the needs assessment Survey
80% 70% 60% 50% 40% 30% 20% 10% 0% Strongly Agree Agree Disagree 6.1% 2.8% 13% 4.6% 1.1% 4.9% 1.3% 0.6% 3.2% 27% 21.3% 29.2% 61% 49.7% 74.1%

Family Friends Healthcare Provider

Strongly Disagree

Don't Know

PeoplewhorespondedtotheNeedsAssessment surveywerevery‘out’tofriends,familyandhealthcare providers.TheywerealsohighlyvisibleasLGBT, with9.1%sayingthatpeoplecanalwaystelltheyare LGBTand40.1%sayingthatpeoplecansometimes tell.Only14.9%saidpeoplecannevertell.

6

Findings
INSURANCEANDSOURCESOFHEALTHCARE

M

anystudieshavenotedthatLGBTpeople havepooreraccesstohealthcarethantheir non-LGBTcounterparts(Cochranetal.,2001; Kerkeretal.,2006;Mayeretal.,2008;Robertsetal., 2004;Valanisetal.,2000).Forexample,according toananalysisofalargepopulation-basedsampleof womeninNewYorkCity,womenwhohavesexwith womenaremuchlesslikelytoobtainmammograms orPaptests(forcervicalcancer)thanwomen whohavesexwithmen(Kerkeretal.,2006). people who Lacked insurance by Sexual orientation and gender identity in the nyS adult tobacco Survey (2004)
35% 30% 25% 20% 15% 10% 5% 0% LGB Heterosexual Transgender Non-transgender 18.5% 14.8% 14.5% 32.9%

Overall, 42% of people said that community fear or dislike of LGBT people was a problem for them in accessing healthcare. These perceived barriers are not without reason. Studies consistently find that LGBT people have more negative interactions with their doctors and are less satisfied with the care they receive.
Similarly,accordingtotheNYCYouthRiskBehavior Survey,youngpeoplewhoidentifyasgay/lesbian (24.5%),orbisexual(22.3%)aremorelikelythanthose whoareheterosexual(18.1%)toNOThavehadaphysical inadoctor’soffice,whichmeansthattheyhaveless accesstohealthcare.OnestaffmemberatanLGBT homelessyouthorganizationexplained,“Mostofthe youngpeoplewhentheycometous,theyweregetting carethroughtheparent/legalguardianandarenolonger [living]withthatperson.TheyweregettingitfromACS [AdministrationforChildren’sServices]oranothercity systemandarenotinthosesystemsanymore.When theycometous,somehaven’tseenadoctorinyears.”

InbothNewYorkCityandNewYorkState,LGBT peopleexperiencelowerratesofhealthinsurance thannon-LGBTpeople.Only14.9%ofheterosexual peopleintheNYCCommunityHealthSurvey(CHS) wereuninsured,while20.6%ofgayandlesbianpeople and23.5%ofbisexualpeoplehadnohealthinsurance. NYSAdultTobaccoSurveydata(showninthegraph above)indicatesthat18.5%ofLGBpeopleand14.8%of heterosexualpeoplewereinsured,andalsothat32.9% oftransgenderpeoplelackedinsurance,compared to14.5%ofnon-transgenderpeople.IntheNeeds Assessmentsurvey,only7.9%ofpeoplewhoanswered questionsaboutinsurancesaidtheyhadnoinsurance. Inadditiontohavinginsurance,havingandusingaprimary careproviderisimportanttohealthcareaccess.According toNYCCommunityHealthSurveydata,28.3%oflesbian andgaypeopleinthesampledidnothaveaprimary careprovider,comparedto17.4%ofheterosexualpeople. However,4.8%ofthoseintheNeedsAssessmentsurvey didnothavearegularsourceofnon-emergencycare, orusedtheemergencyroomasausualsourceofcare.

BARRIERSTOHEALTHCAREACCESS LGBTpeoplefacenumerousbarrierstocare,some LGBT-specificandsomeasaresultoftheirlower ratesofinsuranceandengagementinprimarycare, asmentionedintheprevioussection(Mayeretal., 2008).Theseperceivedbarriersarenotwithout reason.StudiesconsistentlyfindthatLGBTpeople havemorenegativeinteractionswiththeirdoctors

7

andarelesssatisfiedwiththecaretheyreceivethan non-LGBTpeople(White&Dull,1997).Lesbian,gay andbisexualpeople,andparticularlymenwhohave sexwithmenbutdonotidentifyasgay,areunlikely todisclosetheirsexualidentityandbehaviortotheir doctors(Bernsteinetal.,2008;Carretal.,1999). Amongthosebarriersmeasuredinthesurvey,themost importantonewasfinancial,with43.2%ofpeople reportingthatthiswassomewhatoramajorproblem forthem.8Thiswasfollowedcloselyby“community fearordislikeofLGBTpeople”(41.7%).Finally,cultural competencywasanimportantbarriertohealthcare forpeoplewhotookthesurvey,with39.8%ofpeople sayingthatthereare‘notenoughhealthprofessionals whoareadequatelytrainedandcompetenttodeliver healthcaretoLGBTpeople.’Aswillbediscussedin furthersectionsonmentalhealthcare,barrierstomental healthwereanissuetooverone-thirdofthosesurveyed. Culturalcompetency—theabilitytoworksensitively withLGBTpeopleofdiversebackgrounds—wasoneof thestrongestthemesinthekeyinformantfocusgroups. AsthedirectorofoneLGBTcentersaid,“It’sgetting culturallycompetentservicesthat’sthekey…Notall serviceprovidersaregoodatdealingwiththeseissues. Alotofserviceprovidersdon’tallowonformsthatyou liveinadomesticpartnershipsituationoraremarriedto asamesex[partner]…Howdoyouknowwhenyouare dealingwithaserviceproviderwhoisLGBTfriendly?”

Onestaffmemberatanorganizationthatserves LGBTseniorspointedoutthatconcernsaboutcultural competencywerenotlimitedtodoctors.“Ithink manyhelpingprofessionalsdon’tevenrealizethere areLGBTQeldersand…let’snotforgetthepeople inthetrenches,LPNs.Wegotodoctorsand‘high levelprofessionals,’butwedon’tnecessarilylookto trainthefolkswhoarereallydoingthework.Those arethepeoplethatneedthetrainingthemost.” TheLGBTpeoplewhoparticipatedintheNeeds AssessmentareveryinterestedinutilizingLGBT-specific servicesaswellasserviceproviderswhoareculturally competentinLGBTissues.Nearly50%haveusedhealth andhumanservicesspecificallytargetedtoLGBT peopleandnearlythree-quarterssaidtheywouldselect theirprovidersmostlyorsolelyfromalistofculturally competentproviders(ifsuchalistwereavailable).

GEOGRAPHYANDTRANSPORTATION StudiessuggestthatthelackofLGBTsocialnetworks andlackofLGBT-community-specifichealthcarelimit accessforruralLGBTpeople(Willgingetal.,2006).The NeedsAssessmentsurveyshowedthatLGBTpeoplewho donotliveorworkinManhattanaremuchmorelikely tohavedifficultyaccessinghealthandhumanservices becauseofissuesofdistanceandtransportation.For example,21.8%ofthosewhodidnotliveorworkin Manhattansaidthatdistancewasanissueforaccessing

percent of Lgbt people in the needs assessment Survey who Said the Following barriers were problems or major problems in accessing healthcare
50%

40%

39.8% 35.3% 27%

39.2%

41.7%

43.2%

30%

20%

18.9% 10.1%

18.8%

10%

9.8%

0%

Long distances to LGBTsensitive medical facilities

Doctors and other health care workers who refuse to provide services to LGBT people

Fear that if medical personnel find out I am LGBT they will treat me differently

Not enough health professionals who are adequately trained and competent to deliver health care to LGBT people

Not enough Not enough Community fear or dislike of psychologists, psychological social workers support groups LGBT people and mental for LGBT people health counselots who can help me with mental health issues

My personal financial resources

Don’t have adequate and affordable housing

Don’t have transportation to get to the services I need

8

healthcare,whileonly14.0%ofthosewhodidliveor workinManhattandid.Thenumberofpeoplesaying distancewasaproblemroseto29.1%forthoseinrural areas,25.4%ofthoseinsmalltownsand23.0%of thoseinsuburbs.Similarly,transportationwasmore ofanissueforpeopleoutsideoflargeurbanareas. SeveralstaffmembersfromLGBTorganizationsoutside ofNYCspokeabouthowdifficulttransportationand geographicisolationareforLGBTyouth.Onesaid, “Thereareyouthwhodriveanhourandahalftogetto ayouthprogram,”whileanotherpointedoutthatfor someyouth,thatisn’tanoption,“[I]fyou’rea15-yearold youdon’thaveafriendwhocandriveyou.Yournearest clinicmaybeanhouraway...”Whereprogramsdo exist,ruraltransportationoptionsmaynotbeextensive enoughtoserveneeds.Astwostaffmembersfrom anorganizationoutsideofNYCpointedout,“Wehave transportationservices,ourvanpicksupkidsatvarious partsoftheisland,”but“…ourvancanonlypickup15 kids.Theislandishuge.Thatissomethingthatneedsto betakenalookat,…it’sthebarriertoaccesstoservices.” Lackofaccesstoservicesmaybeevenmoreofa problemformarginalizedpopulationswithintheLGBT community.TwostaffmembersatanLGBTprogram outsideofNYCsaid,“LGBTpeopleofcolorwholiveand workoutsideManhattanandothermajorurbanareas faceparticularchallenges…itmaybedifferentfrom [NYC]…wherethingsareprogressed.Here,demographics aredifferent,geographyisdifferent…[Thegeographywe serve]isracially…segregated,andthatisahugeissue.”

In New York City, gay and lesbian people were twice as likely to have a history of depression as heterosexual people.
depression among adults by Sexual orientation in the nyc community health Survey (2007)
30% 25% 20% 15% 10% 5% 0% Heterosexual Gay or Lesbian Bisexual 14.2% 18% 28%

Atotalof16.7%ofthosewhotooktheNeeds Assessmentsurveyhadcurrentprobabledepression, accordingtothePHQ(PatientHealthQuestionnaire), avalidated,two-iteminstrumentformeasuring depressioninepidemiologicalstudies(Gilbodyet al.,2007).BlackandHispanicrespondents,aswell asthosewhowereintheyoungestagegroup(1824)andthosewhoidentifiedastransgenderor gendernon-conforming,weremostlikelytohave probabledepressionthanwereotherrespondents.9 depression among transgender, youth, black, hispanic and all Respondents to the needs assessment Survey
35.0% 30.9%

MENTALILLNESSANDACCESS TOMENTALHEALTHCARE StudieshavelongfoundthatLGBTpeoplearemore likelytoexperiencedepression,anxietyandother mentalillnesses(Balsametal.,2005;Cochranet al.,2003;Kingetal.,2008).Somestudieshavealso suggestedthatthisisduetothegreaterstressthat LGBTpeopleexperience(Meyeretal.,2008).According totheCommunityHealthSurvey,inNewYorkCity, LGBpeoplearemuchmorelikelytohaveahistoryof depressionthanheterosexualpeople.AmongtheCHS respondents,28.0%ofgayandlesbianpeoplehadbeen depressed,comparedto14.2%ofheterosexualpeople.

35% 30% 25% 20%

22.7%

22.4% 17.0%

15% 10% 5% 0% Transgender /GNC Youth Black Hispanic All respondents

9

The same groups at most risk for depression—youth, transgender people and Black and Hispanic people—were those least able to access mental health and support group services.
Inadditiontoexperiencingagreatermentalhealth burden,LGBTpeoplehavelessaccesstomental healthservices.IntheNeedsAssessmentsurvey, 35.3%identifiedlackofmentalhealthservicesand 39.2%identifiedlackofsupportgroupsasbeing aproblemormajorprobleminaccessingcare. BlackandHispanicrespondents,aswellasthose whowereintheyoungestagegroup(18-24)and thosewhoidentifiedastransgenderorgender non-conforming,weremostlikelytohavedifficulty accessingmentalhealthandsupportgroupservices. Lack of access to mental healthcare among transgender, youth, black, hispanic and all Respondents to the needs assessment Survey
Mental Health 70% 60% 50% 40% 30% 20% 10% 0% Transgender /GNC Youth Black Hispanic All respondents 67.8% 57.8% 47.2% 44.6% 40.1% 47.4% 44.9% 35.3% 48.7% 39.2% Support Groups

caresystemthatiscompletelyunpreparedtodeal withtheirneeds.They’reharassed.Theygoofftheir meds,spiraldown,and8-10weeks,they’reback inthehospital.Tobreakthatcycleiswhatwedo. ThequestionIalwaysgetis,whydoesithavetobe twosystems?Whycan’tLGBTpeoplewithmental illnessjustgoandgettreatedintheseprograms?” OneserviceproviderwhoworkswithLGBTurban youthofcolordescribessomeofthesebarriers,saying, “Alotof[youth]sufferfromPTSD,ADD.It’shard gettingthemdiagnosedbecauseourpsychiatristis onlythereparttime.Inorderforustomovetheminto stabilizedandsupportivehousing,theseprograms wantpsychosocialprofilesthatcanonlybedonebya psychiatrist.It’shardgettingthemdone,therearen’t toomanyprogramsthatspecificallydo[this]...” Anotherprovider,aphysicianwhoworkswithboth youthandadults,echoedthattherearecultural competencyissuesinLGBTmentalhealthcare, addingthatthereareadditionalbarriersincultural competencyaroundraceandethnicityaswell: “Generalstigmaaroundmentalhealthservicesto beginwith,particularlyforcommunitiesofcolor, Caribbeanyouthweserve.‘I’mnotcrazy,’‘That’s somethingwhitepeopledo.’Howit’spackagedand promotedisabigpieceofit.Inplaceswhereyoumay finditavailable,somebodyhastohaveinsuranceto accessit.[Andyouneed]providercompetence.”

SUBSTANCEABUSE ResearchsuggeststhatsomeLGBTpeoplesmoke, drinkoruseotherdrugstocopewiththestigmaand violencetheyexperience.Smoking,whichmaylead tolungcancerandotherhealthproblems,iselevated amongLGBTpeople(Gruskin&Gordon,2007;Tang etal.,2004).Alcoholabuseismorecommonamong lesbianandbisexualwomenthanheterosexualwomen (Burgardetal.,2005)andsomestudiesalsofindthis istrueformen(Kingetal.,2008).Finally,illegaldrug useanddependencearemorecommonamongLGBT peoplethannon-LGBTpeople(Kingetal.,2008).

OnestaffmemberatanLGBT-specificmentalhealth treatmentcentersaid,“[Ourcenter]started…because wecouldn’tgetservicesanywhereelse.It’simportant tometoknowwho’sbeingservedandwhatbarriers havetheymetinthenon-LGBTspecificsetting.Our peoplearepeoplewholivewithnothingandincycles ofhospitalization.They’rereleasedintoanoutpatient

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Substance abuse among youth (yRbS) and adults (chS) in new york city by Sexual orientation
60% 56.2% 50% 44.8% 40% 30% 20% 10% 0% Drinking Binge Drinking YOUTH Smoking Binge Drinking Smoking 32.4% 26.1% 20.5% 13.7% 16.9% 7.7% 23.2% 25.6% 20.5% 15.8% 21.3% 17.3% Gay or Lesbian Bisexual Heterosexual

“Housing is healthcare.”
conformingpeopleandBlackandHispanicpeople aremuchmorelikelytohaveeverbeenhomeless. Keyinformantswhoparticipatedinfocusgroups recognizedtheimportanceofhousingtohealthand humanservices.Onestaffmemberofanurbanprogram forLGBThomelessyouthsaid,“Forus,[themost pressinghealthandhumanserviceneed]ishousing… housingishealthcare.Oncewe’vehousedpeoplewho areunstablyhoused,theirlifestylechanges.Iftheyare engaginginunprotectedsex,involvedinstreetwork… oncetheybecomesteadilyhoused,theyaremoreopen toprotectingthemselvesandusingcondoms.Once theybecomehoused,theybecomemoreadherentto medicaltreatment.Whentheyareonthestreet,they arenotadherenttotheirmedicalregimenswithHIV,etc. Theyfeelmoreincontrol,andtheyhavesomewhereto live.It’smorecomfortingandallowsthemtodealwith otherstuff.”Anotherprovider,aphysicianwhoworks withLGBTyouthofcolorsaid,“Asaphysician,I’dgo outonalimbandsay[themostpressingissueis]it’s stablehousingforLGBTyouth,particularlytransyouth.”

27.4%

ADULT

InNewYorkCity,theCommunityHealthSurveyshows thatadultLGBpeoplearemorelikelytosmokeandbinge drink,andtheYouthRiskBehaviorSurveyshowsthatLGB youtharemorelikelytosmoke,drinkandbingedrink. Asonesubstanceabusecounselorwhoworksatan LGBT-specifichealthcenterexplained,substanceabuse issuesvarywithintheLGBcommunity,saying,“We’ve becomeverysophisticatedintryingtofigureoutthe interdependencyofqueerbehavior,HIV,substance abuse....There’smoredevelopmentandsophistication aroundidentifying…highriskbehaviorformen.For lesbians,wehaven’tfiguredoutthebridges.”

SOCIALSUPPORTANDSOCIALISOLATION Socialisolationhasbeenfoundtohavenegativeeffects onhealth,especiallyamongolderadults(Cornwell& Waite,2009).TheNeedsAssessmentfoundthatthe averagescoreonthelonelinessscalewas5.36(outof 9),higherthaninpreviouspopulation-basedstudies (Hughesetal.,2004).Therewasasmallbutsignificant negativecorrelationbetweenageandloneliness, withyoungerpeoplesayingtheyweremorelonely. Transgenderandgendernon-conformingpeopleand peoplewhodonotliveorworkinManhattanwerealso significantlymorelonely.Peoplewhogotoeventsat LGBTcenterswerelesslikelytosaytheywerelonely. Manyparticipantsinfocusgroupsandinterviews suggestedthatlonelinessandsocialisolationwere pressinghealthandhumanserviceneedsthattheir organizationworkstoalleviate.Onedirectorofan LGBTcentersaid:“It’simportanttoqualifysocialization andisolationasadeterminantofpositiveoverallwellbeing,health,self-esteem.Iknowtherearemeasures ofsatisfactioninlifewithhappinessandhealth…

HOUSING Studiessuggestthatasmanyas42%ofhomeless youthareLGBT(Ray,2006).IntheNeedsAssessment survey,nearly14%ofrespondentswerecurrentlyor formerlyhomelessand19%ofrespondentssaidthat inadequateorunaffordablehousingwasanissuein accessinghealthcare.Transgenderorgendernon-

“[LGBT people] definitely need the socialization, the interaction with other LGBT people. They need that sense of gay culture in order to be well.”

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People who go to events at LGBT centers were less likely to say they were lonely.
Wegetalotofpeoplewhodon’tnecessarilysee themselvesasneeding‘hard’serviceslikecounseling, HIVtreatment,buttheydefinitelyneedthesocialization, theinteractionwithotherLGBTpeople.Theyneed thatsenseofgaycultureinordertobewell…It’s hardtodefinethisotherthingforpeopletogetin aroomandhavecoffeeandcake…sharetheirlives withoneanotherandtheirfamilies,theirchildren.” AnotherstaffmemberatanurbanLGBThealth organizationsaid,“Ourfederal,stateandlocaldollars forHIVpreventionareprimarilyspentonindividual andgroupkindsofinterventions,whichareprovento beeffective.However,theyareverycostly.Ifyoudo outreachtothenumberswhoneedtobereached… communitykindsofintervention,buildingcommunity support,tryingtoimpactthevaluesandnormsof thecommunityisamuchbigger,tougherthing. However,theyieldisgreater.It’shardertoevaluate, andthereforegetslessattentionandlessfunding…We seeahugedesireamonggaymenforacommunity connection.Researchhassuggestedthatthose whohaveaconnectiontoacommunityhavebetter healthoutcomes.Thatcomesinallways.African Americanguys…playagameofspades,justtobring asenseofcommunityandcommunitysupport.”

experiences of homophobic violence and Reporting to the police in the needs assessment Survey
Experienced and reported 20% 11.7% 15% 9.9% 10% 7.6% 5.9% 2.4% 13.5% Experienced but did not report

5%

0% 0.9% Neglect 1.0% 5.8% 4.7% Hit, Punched, or Kicked 1.5% Sexual Assault 3.0% Physical Assault Financial Property Exploitation Damage or Blackmail

Despitethehighratesofviolence,theseincidentsoften gounreportedtothepolice.Verbalabuse,forexample, isalmostneverreportedtothepolice.Although5%of thesampleexperiencedhomophobicverbalabuseand reportedit,62.9%experienceditanddidnotreportit. Further,thereissomeevidencethatLGBTpeopleare morelikelytobevictimsofdomesticviolencethen non-LGBTpeople(Olsonetal.,2008).DatafromNew YorkCitysuggestthatthisistruelocallyaswell.For example,the2006NYCCommunityHealthSurvey shows4.5%oflesbianorgayand7.1%ofbisexual peoplereportfearingviolencefromanintimate partner,comparedwith2.3%ofheterosexuals. IntheNeedsAssessmentsurvey,26.4%of respondentsreportedexperiencingintimate partnerviolence;lessthanone-quarterofthiswas reportedtothepolice.Similarly,21.3%reported experiencingstalking,withlessthanaquarterof thosewhoexperienceditreportingtothepolice. Anexecutivedirectorofaseniororganizationin upstateNewYorksuggestedwhyratesofreporting aresolow,saying,“Irunintosomanypeoplethat areusedtobeingtreatedcrappy,theydon’teven reportit.Thatisaboutcomingupinatimewhen thingsweresomuchworse[forpeoplewhoare nowLGBTseniors].Mistrustofpoliceintermsof reporting.Intermsofsame-sexdomesticviolence,I thinkit’sanissuethroughoutsociety…Attitudesfrom othererasplayintoabouthowthingsshouldbe.”

VIOLENCE HateviolenceremainsalargeproblemfortheLGBT community.Forexample,in2007,therewere403antiLGBTincidentsdocumentedinNewYorkCityalone (NationalCoalitionofAnti-ViolencePrograms,2008). IntheNeedsAssessment,13.0%ofthose whoansweredquestionsabouthateviolence reportedhavingbeenvictimsofhomophobic ortransphobicphysicalorsexualassault.

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AstaffmemberfromanotherLGBTprogramsuggested thatforsomeparticipants,violencewasongoingand frommanysources,saying,“Life[forLGBTseniors]has beenrough…[oneoftheparticipantsinourprogram]was marriedtoanabusivehusbandwhobeather,cameout asalesbianandwasmuggedthreetimesasawaitress.”

The Adult Tobacco Survey estimates that there are about 300,000 transgender people living in New York State.
identifyastransgenderorgendernonconformingthan olderpeople.Transgenderandgendernon-conforming peoplewerealsolesslikelytoidentifytheirraceaswhite. NeedsAssessmentsurveydatashowthattransgender andgendernon-conformingpeoplearemuchmorelikely toexperiencebarrierstohealthcare.Morethanthree timesasmanytransgenderandgender-nonconforming peoplesaidthattheywereworrieddoctorswould refusethemcare.Amongtransgenderandgender non-confirmingrespondents,73.4%,ortwiceasmany asnon-transgenderpeople,saidthatlackofwelltrainedproviderswasaproblemfortheminaccessing healthcare.Twiceasmany(56.3%)saidthatfearofbeing treatedbadlykeptthemfromaccessinghealthcare. Atotalof60.2%oftransgenderandgendernonconformingrespondentssaidthatcommunitystigma orfearofLGBTpeoplewasaprobleminattemptingto accessservices.Finally,nearlytwiceasmanytransgender andgendernon-conformingpeoplesaidthathousing wasaproblemfortheminaccessinghealthcare.Three timesasmanytransgenderandgender-nonconforming peoplesaidthattheywerecurrently(3.7%)orformerly (29.6%)homelessaswerenon-transgenderpeople. Stigmaandhomelessnessarebothsignificantbarriers tocarefortransgenderandgendernon-conforming peopleinaccessingappropriate,sensitivehealthcare services.Lackofinformationaboutspecifichealth needsisalsoabarrier.Asonestaffmemberofan LGBTcenteroutsideofNewYorkCityobserved,“[It’s hardtofind]healthcareinformationfortranssexuals intermsofhormones,therapy,properwaytoget andadministerhormonesandtheriskofdoingitthe wrongway[isveryimportant].Tryingtogetthemon thestreetvs.fromaphysician.”Anotherpersonwho worksatatransgender-specificorganizationsaid,“In transcommunities,someofthatresearchistotally missing…researcharoundhormonetherapyoveralong time...[Thereare]nolongitudinal[overtime]studies. Whatcausesalotofpeoplenottoaccesshealthcare isbecausetherearen’treallyanyreliablesources,so

SPECIFICPOPULATIONS transgender and gender non-conforming people TheNYSAdultTobaccoSurveyestimatesthatthereare about300,000transgenderpeoplelivinginNewYork State.Thereisverylittleinformationaboutthenon-HIVrelatedhealthandhumanserviceneedsoftransgender andgendernon-conformingpeople(Mayeretal.,2008). Somepreliminaryresearchsuggeststhattransgender peoplearelesslikelytobeinsuredandmorelikely tobeunemployedandverylowincome.Inboththe NYSAdultTobaccoSurveyandtheNeedsAssessment survey,transgenderpeopleweremuchmorelikelytobe uninsured.IntheNeedsAssessmentsurvey,transgender andgendernon-conformingpeoplewerealmosttwiceas likelyasnon-transgenderpeopletobeverylowincome (20.7%asopposedto11.1%,forhouseholdincomeunder $10,000peryear).AmongrespondentstotheNeeds Assessmentsurvey,youngerpeopleweremorelikelyto

Overall, 28.4% of transgender and gender non-conforming people had experienced a serious physical or sexual assault motivated by homophobia or transphobia. Three times as many transgender and gender-nonconforming people said that they were currently (3.7%) or formerly (29.6%) homeless as were nontransgender people.

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peoplejustdon’tgobecausethey’reafraidofbeing outted,afraidofaccessinganykindofhealthcareatall.” Transgenderandgendernon-conformingpeopleare muchmorelikelytobevictimsofhateviolencethan arepeoplewhoconformtogendernorms.Overall, 28.4%oftransgenderandgendernon-conforming peoplehadexperiencedaseriousphysicalorsexual assaultmotivatedbyhomophobiaortransphobia. people of color IntheNeedsAssessmentsurvey,peoplewhowere Black(24.4%),Hispanic(21.7%),AmericanIndian (26.3%)ormixedrace(19.7%)weremorelikelyto reportlowerincomes(under$10,000peryearfor theirhousehold)andtoreportthattheirincomes werenotsufficienttomeettheirbasicneedsthan wereotherracialandethnicgroups.AmericanIndian respondentswereleastlikelytoreportthattheyhad healthinsurance(72.2%).Blackrespondentswere morelikelytoreportthattheyhadchildrenlivingwith them(21.0%)thanwereotherracialorethnicgroups. Peopleofcolorweremorelikelytoliveinurbanareas. Theywerealsolesslikelytobeemployedandless likelytobepartneredthanwerewhiterespondents. LGBTpeopleofcolorexperiencemorebarriersto healthcareaccessrelatedtorefusalofcareandstigma thandowhitepeople.Forexample,only7.6%ofwhite peopleindicatedthat‘Doctorsandotherhealthcare workerswhorefusetoprovideservicestoLGBTpeople’ wasaprobleminaccessinghealthcareforthem, while21.6%ofHispanicrespondents,18.3%ofBlack respondents,31.6%ofAmericanIndianrespondentsand 14.0%ofmixed-racerespondentssaidthiswasaproblem. Peopleofcolorscoredhigheronthelonelinessscale andweremorelikelytohaveprobabledepression anddifficultyaccessingmentalhealthandsupport groupservices.NearlyhalfoftheAmericanIndian respondentshadprobabledepression,asdidonequarterofBlackrespondents.Asonestaffmemberat anLGBTmentalhealthorganizationsaid,“Whycan’t LGBTpeoplewithmentalillnessjustgoandgettreated in[mainstream]programs?…AnAfricanAmericanwoman mightprefertogotoanorganizationthatisrunby AfricanAmericanwomen.Butsheshouldn’thaveto.” Onereasonthathighratesofbarrierstocarewere reportedmaybebecausecurrentLGBT-specificand

19.3% of Black people and 20.0% of Latino people who filled out the Needs Assessment survey had been physically or sexually assaulted because of homophobia or transphobia, compared to 10.9% of white people.
generalservicesdonotprovideculturallysensitive servicestothefullrangeofpeopleofcolor.Focus groupparticipantswerealsoparticularlyawareof LGBTpeopleofcolorwhoarenotmembersofthose largerracialorethnicgroupsmostoftentargeted forservices.Asonestaffmembersaid,“API[Asian PacificIslander]organizationsneedtobemoreLGBT sensitive,andLGBTorgsneedtobemoreAPIsensitive. APIarenotusuallythoughtofaspeopleofcolor.” Anotherechoedthis,saying,“It’samisnomerthatall peopleofcolororganizationsareBlack.It’samazing withintheLGBTcommunity,whenwewerecreating anagingcurriculum,lackofawarenessofdiversity withinourcommunities.IcomefromaCaribbean background.IunderstandCaribbeanhomophobia. Therearen’tmanywhiteAmericanswhocangointo aCaribbeanspaceandspeakthesamelanguage. Whencreatingculturalcompetencycurriculumor trainings,youhavetobesensitivetotheneedsof targetaudience.”Finally,amemberofatwo-spirit organizationsaid,“Forthetwo-spiritcommunity,weare notbeingrepresentedintheLGBTlargermovement. Wearenotvisibleunlessit’susthat’sdoingit.” Thistypeofsensitivityisnecessary,accordingtokey informants,becauseLGBTissuesplayoutdifferently infamiliesofdifferentbackgrounds.Onestaffmember atanHIVpreventionprogramthatworkswithyouthof colorexplainedthis,saying,“Alotofouryoutharefirst generationfromCaribbean.[Thereare]hugecultural issuesaroundbeinggay,comingfromaCaribbean family…ifthey’regayandHIVpositive,there’stons ofstigma…andabigdisconnectbetweenabilityto beopenincommunity.Createsalotofisolation… There’sabigdifferencebetweenyounggaywhite

14

kidsinNYCwhoaccessservicesandwhereyoung gaykidsofcoloraccessservices…Providingservices thatempoweryounggaymenandwomenofcolor isimportant.Alot[ofkidsofcolor]dealwithracial, cultural,stigmaissues.Thatleadstoothersocialneeds.” Finally,LGBTpeopleofcolorfacemorehateviolence thanLGBTpeoplewhoarenotofcolor.Forexample, 19.3%ofBlackpeopleand20.0%ofLatinopeople whofilledouttheNeedsAssessmentsurveyhadbeen physicallyorsexuallyassaultedbecauseofhomophobia ortransphobia,comparedto10.9%ofwhitepeople. Manyoftheseincidentswentunreportedtothepolice. youth ScholarlyliteraturehasestablishedthatLGBTyouth areatriskforavarietyofnegativehealthoutcomes, includingsmoking,substanceabuse,drinkingand riskbehaviors,aswellasexperiencesofsuicide andviolenceandunsafesex(Goodenowetal., 2002;Goodenowetal.,2008;Russell&Joyner, 2001;Saewycetal.,1999).AlthoughmanyLGBT youthshowremarkableresilience,thestressthey experiencefromhomophobia,bullyingandfamily rejectionoftenleadstoincreasedriskbehavior. InNewYorkCity,LGByoutharemorelikelyto havebeenpregnantormadesomeonepregnant, tohavemissedschoolorbeeninjuredina physicalfight,tohavebeenphysicallyhurtby anintimatepartnerorforcedtohavesex. youth Risk behaviors and negative outcomes in the nyc youth Risk behavior Survey (2007) by Sexual orientation
Heterosexual 30% 25% 20% 17.8% 15% 10% 5% 0% Been pregnant / made someone pregnant Missed school Injured in a physical fight because unsafe Physically hurt by boyfriend / girlfriend Forced to have sex 5.4% 13.1% 11.7% 12% 9.3% 6.5% 5% 7.1% 3.6% 10.2% 6.8% 27.8% 25.5% 20.8% Gay/Lesbian Bisexual

“We know of a case where in Wayne County, social services couldn’t deal with a 13-yearold boy who wants to sew and decorate, and they sent him to Monroe County. What he needs is a sewing machine, not to be shipped off to a different county.”
TheNeedsAssessmentsurveyincluded13%of respondentsbetweentheagesof18and24.Because thesurveycouldnotaskquestionsofpeople under18,thesurveyresultsonyoutharelimitedto thosewhowereinthisyoungadultcategory. Youngadultsaged18-24weremorethansixtimesas likelytoreportthattheyarecurrentlyhomelessthan wereolderadultsinthissample.Severalkeyinformants whoparticipatedinfocusgroupsorinterviews suggestedthathomelessnessforLGBTyouthisoneof themostpressinghealthandhumanservicesissues. AstaffmemberatanLGBThealthcenterexplained thathomelessnessandpovertyhavespecificnegative consequencesforLGBTyouth,saying,“Homelessness [issomething]weseealotamongyoungclientswe workwith.Oneofthethingswehearrecentlyinterms oftheeconomyisthatbasedonthedifficultygetting part-timejobs,peoplelookingforsummerjobs,itlooks liketheremaybemoreyoungpeopleturningtosex workthisyear,thisspringandthissummer,thanhave inthepast…Howdowesupporttheminawaythat doesn’tencounterviolenceandprotectstheirhealth?” TheNeedsAssessmentsurveyshowsthat53.9%of youngpeople(18-24)saythataffordinghealthcareis amajorbarrierforthem.Asanotherstaffmemberata centerforLGBThomelessyouthemphasized,“When they[youth]cometous,somehaven’tseenadoctor inyears.”Foryoungpeoplewhoarenotlivingwith parents,healthcareservicesmaybeunaffordable. Asanotherstaffmembersaid,“Youngerpeopletend tohavethese$10anhourjobs.It’shardforthem toafford[even]lowfeeservices.Theymaynotbe gettinghealthinsuranceforworkingthesejobs.”

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Evenwhenyouthareconnectedtoservices,these servicesmustbeLGBT-sensitiveinordertobehelpful. ThedirectorofanLGBTcenterinupstateNewYork articulatedherfrustrationswiththesocialservicesystem, saying,“[Weknowofa]casewhereinWayneCounty, [socialservices]couldn’tdealwitha13-year-oldboywho wantstosewanddecorate,andtheysenthimtoMonroe County.Whatheneedsisasewingmachine,nottobe shippedofftoadifferentcounty.”Anotherstaffperson atadifferentLGBTcentersaid,“Whenayoungperson isplaced[infostercare],LGBTorperceived,iftheyare avictimofharassmentorbullying,oftentimesthey’re theonethatgetsmovedfortheirprotection.Rather thandealingwiththeissueofviolenceofperpetrators, thevictimofthebehaviorgetspunishment.” Finally,youthofcolorfacespecificissuesaround accesstocareandservices,andsomeofthoseneeds aredifferentforyouthofcolorwholiveoutsideof majorurbanareas.Asthedirectorofaprogramfor LGBTpeopleoffaithsuggested,“[Themostpressing healthandhumanserviceneedis]thelackofservices forLGBTyoungadults.Agecategory18-30ofcolor inthecommunitiesthataremoreunderserved[are] marginalizedbyothervariablesintermsofpoverty [and]unemployment…[Theybenefit]iftheyfeel comfortablegoingtohealthprovidersbecauseofallthe stigmaandbarrierstheyface.”Asastaffmemberata programworkinginaNewYorkCitysuburbexplained, “The[suburban]youtharepredominatelyCaucasian andhavetremendousservices.Theyhaveallsortsof social,familial,andscholasticsupport.Asopposed to…youth[ofcolor],whohavedroppedoutofschool becauseofharassment,whoaren’tgettingservicesmet, they’rehavingahardtimecomingouttofamilies.” Seniors ResearchonLGBTseniorssuggeststhatthey,like youth,haveuniqueneeds.Particularlybecausethey aremorelikelytoagealonethanheterosexuals andareheavilyinvolvedincaregiving,manyof thoseneedsinvolvesocialsupportaswellasneeds thatmightbeexpectedforsomeonewhoisaging (Cahilletal.,2000;Coon,2003;Hash,2006). AccordingtotheNYCCommunityHealthSurvey, inNewYorkCityalonethereareatleast8,000 LGBseniorsatriskforsocialisolation.Social

According to the NYC Community Health Survey, in New York City alone there are at least 8,000 LGBT seniors at risk for social isolation. Older LGBT people who lived in small towns or did not go to events at LGBT centers were significantly more lonely.
isolationhasmanydifferentcauses,manyofthem rootedinLGBTseniors’historieslivinginanintolerant socialworld.Theseniorissuesfocusgroupagreedthat themostpressinghealthandhumanserviceneedfor LGBTseniorsissocialisolation.Onestaffmemberatan LGBTagingorganizationexplained,“[SocialIsolation] meansalotofthingsinvariousmanifestations.Some otherscanspeaktothisbetterthanIcanbecause ithastodowithlivinginotherurbanareas.People nottrustingservicesornotbeingabletoaccess. Beingsuspiciousofnotbeingtreatedwell,especially aspeoplegetoldandfrail.Peoplejustdistancing themselvesfromcommunitycreateshugedisparities intermsofhealth.Isolationisthebigumbrella…The mostpressing[problemrelatedtosocialisolation]… istheinternalizedhomophobiawhichcanleadtothe isolation,leadtoalcoholism,abuseofalcohol,suicide.” Sixteenpercentofpeoplewhotookthesurveyidentified thattheywereage55-64and6%saidthattheywere over65.Olderadultssometimesneedassistancein accessinghealthcareandassuringtheirownwellbeingastheyage.However,thegroupofseniorswho tookthissurveyhadstrongresourcesindealingwith barrierstohealthcare;theyratedeachofthebarriers lessofaproblemthandidyoungerrespondents.On theotherhand,overhalfofseniorssaidthatthey sometimes(36.1%)oroften(22.1%)feeltheylack companionship.Seniorsinsmalltownsweremuch morelikelytosaythattheylackedcompanionship often(37.3%)thanwereseniorsincities.OlderLGBT

16

LGBT seniors are vulnerable to financial exploitation and neglect.
peoplewholivedinsmalltownsordidnotgotoevents atLGBTcentersweresignificantlymorelonely. SeniorsalsoconfrontageismwithintheLGBT community,andhomophobiaandtransphobiainnonLGBTsenior-specificcontexts.Onestaffmemberat anLGBTcenterpointedout,“Ageismisrampantin oursocietyingeneral.Everybodyages.Hopefully we’llallage.WithintheLGBTcommunity,itgetsto anotherlevel.Iseeitinourprogram,thereisastigma attachedtoattendingourprogram…Wedesexualize seniors.Infact,they’restillouttheregettingiton.” Finally,LGBTseniorsarevulnerabletofinancial exploitationandneglect.Ofthose55andolder whotookthesurvey,8.3%hadexperienced neglectasaresultofhomophobiaand8.9%had experiencedfinancialexploitationorblackmail. Verylittleofthisabusewasreported. Families OverhalfofthosewhotooktheNeedsAssessment surveyarepartnered,suggestingahighrateof familyformationamongLGBTadultsinNewYork State.FormanyLGBTpeople,theabilitytobuilda familyisapressinghealthandhumanserviceneed. OfthosewhotooktheNeedsAssessmentsurvey, 13.1%havechildrenlivingwiththematleastpart time.LGBTpeoplemakefamiliesinavarietyofways (Weston,1997),includingconnectingwithother LGBTpeopleofdifferentgenerations,adopting andfosteringchildren,pregnancyandsurrogacy. However,intheireffortstoformfamilies,LGBTpeople mayfacemanybarriersaswellasopportunities. Oneparticipantinthefocusgroupswhoisalsothe directorofanLGBTfamiliesprogramemphasized theopportunitiescreatedbyLGBTdesirestoform familiesinnon-traditionalways,saying,“Inafostercare conversation,wejustopenedaflood-gate.Wemade onecontactwithahome-finderrecruitmentperson fromaprivatefostercareagencyintheBinghamton area[whotoldme],‘IknowLGBTparentsmakegreat parents,helpmefindthosepeopleandhelpmehow toconvinceolderkidsinfostercarethatgoinginan

LGBT-parentedhomewouldbeokay.’…Publicwelfare agencyfolks[are]talkingabouttheprocess,trying torecruitqueeradultsintobeingfosteradultsand [tellthemthey]won’tfindhomophobiawhenthey gotoaDHSoffice.”However,shealsoacknowledged thechallenges,saying,“Wearenotprovidingenough supportforcouplesconsideringparenting,becoming parents,toreallybepreparedforwhatthatmeans. I’mgettingcallsforreferralstoattorneys,mediators tosortoutbreakups.Tryingtocheckoutmediation placetoseehowhomophobictheyarebeforeIrefer.” Otherchallengesemergeinthehealthcarecontext forLGBTpeopletryingtoformfamilies.Onekey informantwhoworkswithLGBTpeopleofcolor infaithcommunitiestoldthisstory:“Wehavea22 or23[yearold]lesbiancouple.Oneispregnant.I said,‘Hasyourpartnerattendedanyofthedoctor appointments?’[Shesaid]‘Notyet.’Irealizedit’s takingmeback.Thereareotherissues.Thedoctor doesn’tknowshe’salesbian.He’sareputabledoctor. Shedoesn’twanttotaketheriskofthedoctornot treatingherinaprofessionalmanner.Wespentsome timelookingatthat…Issuescameuparoundtheir ownconcernsofbeingalesbianandamother.” Althoughthereisverylittlequantitativedataon thisgroup,childrenofLGBTparentsmayhave particularhealthandhumanserviceneedsaswell. Anotherstaffmemberwhoworkswithfamilies said,“IwouldsayalsoservicesforourFamilyPride organizationthatisforsame-sexparentsandtheir children.Thereisagreatneed…wecanonlycombine allthechildrentogether,doesn’tmatterifthey’re newbornor17.Iseeagreatneedforteenagersof LGBTparentstohavegroupstocometogether.”

“We have a 22 or 23 [year old] lesbian couple. One is pregnant. I said, ‘Has your partner attended any of the doctor appointments?’ [She said,] ‘Not yet.’”

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NextSteps:AreasforFutureFocus
population Size and demographics DespitetremendousprogressinLGBTinclusioninNew YorkCity,andtheimportantinformationfromthe2004 NYSAdultTobaccoSurvey,statewidehealthsurveys andotherdatacollectionneedtoconsistentlyinclude reliable,validquestionsaboutLGBTidentity.Without furtherresearch,healthandhumanservicesneeds cannotbereliablytracked.Particularattentionshouldbe paidtothelackofdataontransgenderpeople.Restoring thequestionabouttransgenderidentitytotheNYSAdult TobaccoSurveyandotherstatewidesurveys,andadding thisquestiontotheCommunityHealthSurveyinNew YorkCitywouldbeimportantstepsinthatdirection. insurance and Sources of healthcare LackofinsuranceremainsanissueformanyLGBT people.Expandingaccesstoaffordableinsurance andremovingbarrierstocoveragefordomestic partnersandspouseswouldhelpcoveruninsured LGBTpeopleandnarrowthecoveragegapbetween LGBTandnon-LGBTpeople.LGBTadultsandyouth alsoneedtobeengagedinprimarycareandhave regularcheck-ups.ExpandingaccesstoLGBTfriendlyprovidersandencouragingLGBTpeopleto havearegularsourceofcarewillimprovehealth. barriers to healthcare access Culturalcompetencytrainingforhealthcareproviders willhelpalleviatemanyofthebarrierstocarethatwere reportedintheNeedsAssessment.Further,advertising statingthatprovidershavebeentrainedwouldallow LGBTpeopletoselecttheseprovidersandutilizethem. geography and transportation Fornon-urbanLGBTpeople,especiallyyouthofall racesandadultsandyouthofcolor,transportationis crucialtothesuccessofprograms.Wheretransportation isnon-existentorinsufficienttomeetneeds,further transportationoptions(forexample,vansand driverstodriveyouthtoprograms)arenecessary. Increasingservicestoruralareaswillalleviate socialisolationandthehealthandhumanservices problemsthatarisewhenLGBTpeopleareisolated. mental illness and access to mental healthcare Mentalhealthservicesandsupportgroupsfor LGBTpeopleneedtobeexpanded.Lackofthese serviceswasconsideredtobeapressingneed forallLGBTpeople,andparticularlyforyouth, transgenderpeopleandBlackandHispanicpeople. Substance abuse Tobacco,alcoholandotherdrugscontinuetotakea disproportionatetollontheLGBTcommunity.Further researchisneededintothemosteffectivewaysto helppreventthisandhelpthosewhoareaffected. housing and homelessness LGBTpeoplearedisproportionatelyaffectedby homelessness.Expansionofhomelessservices, LGBTsensitivitytrainingforprovidersintheshelter systemandanincreaseinLGBT-specifichomeless serviceswillhelpalleviatethisproblem. Social isolation Lonelinessandsocialisolationcanhavesignificant negativehealthimpacts.LGBTcentersandother communitybasedorganizationscanhelpprovidesocial programsandcreatespacesforpeopletomeet. violence HateviolenceremainsaproblemforLGBTpeople. Servicesforvictimsandpreventionprogramsneed continuedsupport.Further,hateviolenceoften goesunreported.Inordertoimprovereporting,it isimportanttoensurethatpoliceareadequately trainedtoworksensitivelywithvictims. transgender and gender non-conforming people Loweringbarrierstohealthcareandhumanservices beginswithmoreresearchontransgenderandgender non-conformingpeople’sspecifichealthcareneeds. Healthcareproviderscanshowpeoplewhodonot identifyas‘male’or‘female’thattheyaresensitiveto theseissuesbychangingtheirformstoincludemore thantwogenderoptions,orreplacingcheckboxeswith fill-inblanks.Becausetransgenderandgendernonconformingpeopleexperiencehighratesofviolence,

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safeschoolsprogramsandprotectionfromviolence andprejudiceinpublicplacesareparticularlyhelpful tothisgroup.Theseprogramsmustbeenforcedand begender-identityinclusiveinordertobeeffective. people of color LGBTpeopleofcolorfaceuniquechallengesin accessinghealthandhumanservices.Theyaremore likelytoexperiencepovertyandhomelessness. LGBTservicesmustbesensitivetothedifferences incultureamongracialandethnicgroupsand providesupportthatisculturallyappropriate. youth LGBTyoutharevulnerabletoviolence,homelessness, riskbehaviorsandothernegativehealthoutcomes. IncreasingsocialservicestargetedtoLGBTyouth canalleviatethesedisparities,whiletrainingsocial serviceproviderswhoworkwithyouthincultural competencyforLGBTissueswillmeanthatyouth whoaccessservicesareprovidedadequatecare. Seniors Seniors,especiallythoseoutsideofmajorurban areas,needopportunitiestosocializewithother LGBTseniors.Seniorsareoftenresilientandprovide caregivingtootherseniors;however,theyneed LGBT-sensitivehealthandhumanservicesoptions. LGBTservicesneedtobesensitivetogenerational differences,withanunderstandingthatmany LGBTseniorscameoutatatimewhenbeing LGBTwasmorestigmatizedanddangerous. Families LGBTpeopleformfamiliesinavarietyofways; thesefamiliesdeservesupport.LGBTpeoplewho wanttobeparentsshouldbetreatedequallyby adoptionagenciesandthefostercaresystem.

1 Peoplewhoidentifiedtheirsexualorientation as‘samegenderloving’or‘homosexual’were categorizedwithgayandlesbianpeople. 2 Population-baseddataiscollectedtorepresentthe entirepopulationandthusprovidesstrongerestimates thandatacollectedthroughconveniencesamples. 3 NewYorkCityDepartmentofHealthandMental Hygiene.Epiquery:NYCInteractiveHealthDataSystem- CommunityHealthSurvey2007andYouthRiskBehavior Survey2007.6May,2009.nyc.gov/health/epiquery 4 Peoplewhoreportedanageunder18orweremissing zipcodes(anddidnotliveorworkinManhattan)or whoreportednon-NewYorkStatezipcodes(anddid notliveorworkinManhattan)wereexcluded.People whoidentifiedasstraightandnon-transgenderand whosebirthsexmatchedtheircurrentgenderidentity wereexcluded.Peoplewithmorethan50%missingdata wereexcluded.ThedatawereanalyzedusingSPSS. 5 Thisinformationcanbefoundintables14and15in: MosherWD,ChandraA,JonesJ.Sexualbehaviorand selectedhealthmeasures:Menandwomen15–44years ofage,UnitedStates,2002.Advancedatafromvital andhealthstatistics;no362.Hyattsville,MD:National CenterforHealthStatistics.2005.Viewedon6May 2009at:www.cdc.gov/nchs/data/ad/ad362.pdf 6 Transgenderandgendernon-conforming,asacategory, includedself-identifiedtransgenderpeople,peoplewhose currentgenderidentitywasdifferentfromtheirbirth sexandthosewhoidentifiedthemselvesasgendernonconforming,genderbendingorsimilar.Althoughthiscategory isdiverse,itwasconsideredonegendercategoryinorder tohaveasufficientnumberofrespondentsforanalysis. 7 Itisnotpossibletoknowwhetherthemarriedsame-sex partnersweremarriedlegallyinanotherstateorcountryor whetherthepartnerssimplyconsiderthemselvesmarried. 8 ThesurveymeasuredbarrierstocareusinganLGBTspecificmodificationofanHIVbarrierstocarescale. TheoriginalscalecanbefoundinHeckman,Somlaiet. al.(1998)BarrierstocareamongpersonslivingwithHIV/ AIDSinurbanandruralareas.AIDSCare10:3;365-375. 9 BlackandHispanicrace/ethnicitywas aloneorinanycombination.

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Acknowledgements
ProducedwithfundingfromtheNewYorkState DepartmentofHealth,DivisionofFamilyHealth.The opinions,results,findingsand/orinterpretationsofdata containedhereinaretheresponsibilityoftheauthorand donotnecessarilyrepresenttheopinions,interpretation orpolicyoftheDepartmentorStateofNewYork. SomjenFrazerwouldliketoacknowledgetheinvaluable assistanceoftheTechnicalAssistanceCommitteeofthe LGBTHealthandHumanServicesNetwork,including BarbaraWarren,ChristianHuygen,HarlanPrudenand JoanneGoodman.ShewouldalsoliketothankRossLevi andKimberlyEisenfortheirexcellentworkrepresenting theEmpireStatePrideAgendaFoundation.Inaddition, TomWeber,KarenTaylorandSunnyBjerkfromSAGE providedadviceandassistancewithfocusgroups. WithoutAmandaHarris,projectmanagerfortheresearch andoutreach,thisworkwouldnothavebeenpossible. AllmythankstoEstherBakerforherqualitativeresearch andcopyediting.Finally,allthosewhoparticipatedinthe researchandsharedstoriesinfocusgroups—thisreportis firstandforemostforyouandbecauseofyou.

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Frazer,M.Somjen.(2009)LGBTHealthandHuman ServicesNeedsinNewYorkState.EmpireStatePride AgendaFoundation:Albany,NY.URL.AccessDate.

empiRe State pRide agenda Foundation OneCommercePlaza 99WashingtonAvenue,Suite805 Albany,NY12260 518-472-3330 16West22ndStreet 2ndFloor NewYork,NY10011 212-627-0305

www.prideagenda.org

FormoreinformationaboutthedataorNeeds AssessmentpleasecontactSomjenFrazerat: www.somjenfrazer.comor consulting@somjenfrazer.comor 646-233-2019

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“couldnotfindagayprimary I caremedicaldoctorinthe suburbsandhavetogoto thecity.”

“ nowingwherehealthcareprofessionals K standontheirbeliefsandattitudeswould beextremelyhelpfulinchoosingdoctors— especiallywhenplanningafamily.”

“wouldlovetogotoanLGBT-friendlydoctor,butIdon’tknowwheretofindone.Mycurrentprimarycare I providerdidnotdiscriminateagainstme,butsheknewverylittleaboutlesbiansexualhealthconcerns.It seemstobeaverycommonproblem.Manyofourprovidersarenotwell-informedaboutqueerwomen’s healthconcerns.”

“ hemostimportanthealthandhumanserviceneedforLGBTpeopleisfair,equalandpersonalizedhealthcare.Once T Iwenttoalocalhospital,theydidn’tseemeasagaymanatrisk.Myprimarycarephysicianshouldknowhowtotreat me.IhavefoundinmostcasesthatonlysomeonewhocaresaboutorisintheLBGTcommunityknowshowtotreat me.Thisisunfairandunequal.”

“rememberwhenIfirstbecameHIVpositivenotbeingabletofindasupportgroupthatwasnotprimarily I acontrolledstudy,andthereforeit’sownfirstpriority.IwasshockedathowcallouslyIwastoldtoapplyfor anothergroupstartingin12weeksorsowhenIfeltIwasincrisisthen.”

“ veryNewYorkershouldbeconfidentthattheycanaccessLGBT E knowledgeableandsensitivehealthcarewhentheyneedit.Healthinsurance shouldbemoreaccessible,andtransition-relatedhealthcareshouldnotbe excludedbyinsurancecompanies.”

“ ro-activewelcomingandhonestoutreachinacentralclearinghousewhereallLGBTpeoplecango, P feelsafeandenthusiasticallysupported,toobtainreferralstoallhealthandhumanservicesresources availabletothem.Followupshouldalsobepro-activetoensuretheLGBTpersongotrightleadsand theneedisbeingaddressedwithredirectionasneeded.”

“ ostofthediscriminationaroundhealthcarethatIreceiveisbecauseI’mfat.I M finditextremelydifficulttofindnonfat-phobicmedicalservicesevenwithinthe LGBTcommunity.Iwouldliketoseemoreofaneffortmadeforsensitivitytowards peopleofsizeinhealthandhumanservices.”

“ sychologicalcounselorsneedtobetrainedinhowtodeal P withLGBTissuesconsideringtheprevalenceofmentalissues amongtheLGBTpopulationandtheuniquestressorswithin thatpopulation.”

“t’simportanttohavetheHPV I vaccineavailabletomenand coveredbyinsurance.”