Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people in the U.S. experience numerous sexual health and sexual health care inequities compared to cisgender, heterosexual people. However, LGBTQ+ sexual health research has overwhelmingly focused on HIV/AIDS, while comparatively little research documents LGBTQ+ individuals’ experiences navigating sexual health care. Further, existing studies overwhelmingly represent the experiences of White LGBTQ+ individuals, limiting understanding of the experiences of LGBTQ+ people of color who, theoretical literature suggests and limited empirical studies have shown, experience particularly pronounced sexual health inequities due to their location at the intersections of multiple systems of oppression and inequality. Informed by theoretical frameworks of intersectionality, stigma, and socio-structural determinants of health, this multiple methods dissertation examines how stigma impacts the sexual health and gender affirming care experiences of LGBTQ+ people assigned female at birth (AFAB). The project combines nationally representative data from the National Survey of Family Growth with data from 76 in-depth interviews conducted between 2019 and 2021 with a racially/ethnically diverse sample of 64 LGBTQ+ individuals AFAB recruited from the San Francisco Bay Area. Three empirical chapters comprise this dissertation. Chapter 3, which draws on U.S. survey data from the National Survey of Family Growth, finds that White, Black, and Latina bisexual women and Black or Latina lesbian women aged 15-44 years have higher odds of a medical provider having asked them questions about their sexual behavior compared to White heterosexual women. Notably, Black bisexual women have the highest predicted probability of having been asked these questions in the past year, which may be a reflection of assumptions of promiscuity rooted in both racism and biphobia. The first and third empirical chapters use constructivist grounded theory methods to qualitatively examine sexual health and gender affirming care seeking and care experiences among a racially/ethnically diverse sample of LGBTQ+ people assigned female at birth. The first chapter identifies interpersonal and structural factors¬–primarily related to anticipated and experienced interpersonal stigma and discrimination (e.g., heterosexism, (cis-)sexism, racism) and experiences of inclusive, affirmative, and person-centered care–that inform sexual health and gender affirming care seeking and quality of care. I find the impacts–both positive and negative–of these factors are particularly heightened in the contexts of sexual health and gender affirming care and for multiply marginalized patients. The third chapter illuminates strategies that LGBTQ+ people assigned female at birth use to navigate barriers in order to obtain needed care and, at times, resist oppressive practices and policies. Combined these two chapters point to the role of trusting patient-provider collaborations in shaping patients’ care seeking and quality of care.
As (re-)illuminated and exacerbated by the COVID-19 pandemic, health inequalities reflect broader social inequalities yet are often over-attributed to individual decisions and behaviors, particularly without recognizing how individual behaviors are shaped and, often, constrained. This dissertation examines how sexual health care inequities among LGBTQ+ people assigned female at birth manifest and are reproduced through health care practices and policies, which uphold systems of power and oppression. Findings point to the importance of structurally competent, anti-oppressive health care programs, policies, and practices in order to advance health equity for all.
