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Abstract

Patient–clinician communication and experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults, particularly lesbian and bisexual (LB) women, in health care settings have historically been fraught with challenges, including discrimination and lack of inclusivity. This qualitative study, employing a community-based participatory research approach, aimed to explore the experiences and recommendations of LB older women and their chosen care partners in the Deep South. Two focus groups conducted over Zoom revealed seven recurring themes and three sub-themes, highlighting crucial aspects of health care delivery. Themes included the importance of initial interaction, collaboration with patients, effective communication, extended patient–doctor time, equitable treatment, training on bedside manner and self-awareness, and addressing disparities within the health care system. Findings underscore the significance of patient-centered care, shared decision-making, and recognition of patient values in improving health care experiences and outcomes for LGBTQ+ older adults, particularly LB women. Findings highlight the crucial role of initial interaction in fostering trust and cooperation, collaboration in decision-making processes, and allocating adequate time for comprehensive care delivery. Effective communication strategies, including thorough explanation of medical processes, inclusive language, and patient-centered communication, emerged as vital components. The study underscores the significance of recognizing diverse identities and intersectional experiences, particularly for African American LB older women, and advocates for promoting inclusive health care practices to improve health equity and patient satisfaction. Implementing these insights into clinical practice and policy development can lead to more inclusive health care environments tailored to the needs of LB older women.

Introduction

Patient–clinician communication

Experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults, including diverse populations (e.g., race and ethnicity) within the broader community, and in particular lesbian and bisexual (LB) women in health care settings historically have shown to be fraught with challenges, most significantly around discrimination, lack of inclusivity, poor patient–clinician communication, lack of acknowledgment or inclusion of spouses and partners, and failure to collect sexuality and gender identity data leading to a lack of holistic understanding of the patient.^1,2 Some resulting mental health-related challenges that have been experienced are depression, anxiety, suicidal ideation, and attempts.³ African American LGBTQ+ older adults have identified specific issues around the quality of medical care, being under-prioritized, and having to advocate for basic care.⁴ Because of these barriers, which continue to affect patient care, several health disparities persist, including obesity, diabetes, chronic heart disease, and many cancers.^5,6 Previous research has also identified that improved patient–clinician communication can help bridge these gaps and help address issues around health equity for LGBTQ+ older patients.⁷

Intersectionality and goal concordant care for LGBTQ+ older adults

We have experienced in the past decade minor improvements in inclusive, goal-concordant care for LB older women; however, each patient’s unique intersectional identities must be incorporated into their care.⁸ The importance of goal-concordant care cannot be overstated; if patients receive care that runs counter to their wishes, or their wishes are not established during the trajectory of their illness, patients may face serious harmful outcomes related to their illness. In addition, both patients and families may experience lower quality of care and less communication which may negatively affect the overall health care experience.^9,10 Research on communication between clinicians and diverse LGBTQ+ patients has identified several areas of concern that continue to merit attention.¹¹ Health care professionals who identify and acknowledge the multiple identities of LGBTQ+ older adult patients—including intersections of race, ethnicity, socioeconomic status, region, and ability—and construct care plans based on patient needs have positive interactions with these patients and those whom patients choose to include in their care (e.g., spouses, partners, chosen family).¹² On the contrary, health care professionals whose understanding of their diverse LGBTQ+ older patient populations and patient needs are lacking, often fail to provide equitable, goal-concordant care or develop positive relationships with their patients.¹³ Recognizing important aspects of a patient—such as whom they consider important in their lives and what they want from a health care practitioner—as well as adjusting communication and creating an inclusive environment can improve all aspects of care. Perceived support, positive communication, and equity allow LGBTQ+ older patients to avoid barriers to care, which in turn may affect their experiences during their time in the health care system.⁸ In addition, to ensure health equity for LGBTQ+ older women of diverse intersectional identities, it is critical to recognize the history of discrimination faced by LGBTQ+ communities and how it has affected attitudes toward health care.¹⁴

Importance of honoring patient perspectives

In the era of heightened accessibility to health information facilitated by the internet, there is a noticeable shift toward individual accountability and the endorsement of personalized medicine. This transformation aligns with a growing demand for patient-centered care, cultural humility, active patient participation, and empowerment,¹⁵ all of which are deemed crucial for the future of high-quality health care by the National Academy of Medicine, previously the Institute of Medicine.¹⁶ Critics argue that the prevailing paternalistic approach to patient care overlooks patient preferences, fostering dependency (e.g., deferring to the health care professionals without questioning any recommendations). In contrast, a more empowered patient approach could grant older LGBTQ+ individuals greater control over their lives, enabling better integration into society and the workforce.^15,16 Adding an intersectional lens to the issues around preferences for African American primary care practitioners and for better cultural understanding than health care professionals of other races and ethnicities allows for a greater understanding of the needs and preferences of African American LGBTQ+ women.

Inclusion of black voices in health care research

Recent research has focused on the perspectives of Black individuals within the health care system¹⁷ as well as provided suggestions as to how to increase diverse perspectives in research.^18,19 Here has also been research that has explored clinicians’ perspectives about racism in health care.²⁰ With the acknowledgment of worse health outcomes for Black patients than their white counterparts, other research has highlighted the importance of taking the perspective of Black patients within the health care system to decrease the deleterious effects of racial bias.²¹ Further, researchers and research participants have called for the increased inclusion of Black perspectives in cancer research in the hopes of achieving more generalizable information to be implemented in treatment.^19,22

How do LGBTQ+ populations make health care decisions?

Patient-oriented care, grounded in respect for patients’ preferences, needs, and values, emphasizes interaction on equitable terms.²³ This fosters shared decision-making, a pivotal concept in patient empowerment, patient participation, and the culmination of patient-centered care.^24,25 For diverse LGBTQ+ patients, research has shown a critical need for clinicians to engage patients in health care decisions, paying close attention to patients’ and loved ones’ beliefs, values, and preferences for care. LGBTQ+ older adults from racially and ethnically diverse backgrounds have noted their reluctance to engage with health care professionals who do not engage in collaboration with patients and thus fail to establish and build trust, a critical concept in decision-making.²⁶ Shared decision-making assumes that patients are well-informed about therapeutic options and their potential effects on preferred outcomes. This enables patients to actively engage in discussions with health care providers, ensuring treatment decisions align with their personal expectations and values, such as uniqueness and autonomy. Research has shown historical challenges for African American older adults stemming from assumptions by health care professionals that patients lack understanding of medical or clinical information and have limited knowledge of their health outcomes. African American patients feel they may also receive less advanced care based on their race as compared to White counterparts, and while the majority of LGBTQ+ individuals, regardless of race or ethnicity, report experiences with poor treatment by health care professionals, African American LGBTQ+ individuals attribute this treatment to their race as well as their sexuality or gender identity.²⁷

A review delving into patient values identified seven themes: uniqueness, autonomy, compassion, professionalism, responsiveness, partnership, and empowerment. These values pertain to the individual patient, the expected behavior of health care professionals, and the interaction between patients and health care professionals.²⁸ Despite these advancements, individuals with chronic illnesses remain heavily reliant on technical medical expertise. Lack of understanding and insight by health care professionals into patients’ experiences, including compassion and responsiveness, may lead to mistrust, feelings of abandonment, isolation, or alienation.²⁹

Patients with chronic diseases often grapple with existential struggles as they attempt to make sense of their illnesses, sometimes resulting in self-blame. The perception of being a “bad patient” and taking personal responsibility for lifestyle choices can adversely impact their quality of life.³⁰ Effective communication and understanding between patients and health care professionals are crucial to mitigate these negative effects.³¹ Identifying potential disparities between patients’ health care values and what they receive is essential.³² These discrepancies may stem from differences in prioritizing values between health care professionals and patients, as making sound treatment decisions involves not only scientific evidence but also value judgments.³³

Methods

Design

This descriptive qualitative study employed focus groups to understand the experiences of the participants. We used a community-based participatory research (CBPR) approach wherein community members from the LGBTQ+ community collaborated with academic health care researchers to address health disparities.^14,34 CBPR effectively develops and implements community-focused and led studies and seeks to identify improvement in health outcomes for the population.³⁵ This study is the first in a planned multi-phase approach to ultimately provide training to health care providers to improve the lives of the community members through the suggestions and perspectives of those community members. This research was about what the community members knew and needed.

Participants and recruitment

We partnered with a Community Advisory Board (CAB) which guided the team in all aspects of the project. Ten female-identifying LGBTQ+ older adults comprised the CAB drawn from seniors’ groups in Alabama and Georgia. CAB members lived in the Deep South, identified as either African American/Black or White, and had been patients or caregivers for someone living with serious illness. CAB members participated in 12 meetings. Prior to initiating the focus groups, the CAB met 12 times to create recruitment materials for the study, agree upon the IRB-approved consent form, design the interview guide, and define the strategy for recruitment of participants. Focus group interviews were conducted with LB women living with serious illness and their chosen care partners. All participants lived in the Deep South, identified as women, identified as either African American/Black or White, were at least 50 years of age, and had been either a patient or chosen caregiver for an individual living with serious illness. Focus group facilitators were members of the same sub-group (African American/Black or White) to build trust and encourage open discourse during the interviews.³⁶

Data collection

The CAB and the academic research team constructed a nine-question, semi-structured interview protocol, and two separate focus groups were conducted over Zoom. The focus groups were composed of 10 White women and 7 Black women, respectively. Additionally, 16 of the women identified as lesbian, and one identified as bisexual. There is evidence for the benefit of conducting online focus groups with marginalized or geographically remote populations, in particular when the research question(s) are sensitive.³⁷ Each focus group met either four or five times for two hours, allowing all participants the opportunity to voice their opinions, share their experiences, and provide deep, meaningful content for each interview question.

Data analysis

Focus group recordings were transcribed verbatim. Transcribed interviews were imported and coded using Delve Software. We used reflexive thematic analysis to generate initial themes, and researchers followed a semantic and latent approach³⁸ to create themes identified from the explicit meaning of the interview data.³⁹ Two raters separately reviewed and coded the data which was then discussed to determine agreement until consensus was reached. To ensure the derived themes accurately reflected the intentions of the CAG and authentically represented the participants’ experiences, the findings were iteratively shared with both groups. Thematic analysis results were presented incrementally, fostering focused discussions on each theme with the CAG and focus group members and incorporating their feedback on language and interpretation. This iterative process enhanced the trustworthiness of the study’s findings.⁴⁰ An audit trail and memos were maintained throughout.

Methodological integrity

We established trustworthiness and purposeful implementation of reflexivity, in particular, discussing each coder’s analysis and process (e.g., naming of codes, memoing, theme generation, mind mapping), which aided in establishing reliability, transferability, and validity.³⁸ Trust was also established through continued engagement with the CAB in order to best understand their perspectives and process, as recommended by Lincoln and Guba,⁴¹ Erlandson et al.,⁴² and Morse.⁴³ We recruited from several states within the Deep South in order to engage in site triangulation and because CAB members were represented within multiple communities. We kept a detailed description of all data gathering and documented how such contexts influence data analysis and interpretation in order to conform to transferability expectations. We maintained an audit trail and kept journal entries⁴⁴ as well as reflective journals for reflexivity.³⁸ All measures of trustworthiness were maintained through a shared drive to which all research team members had access to be able to see what each person’s thought process was and how decisions were made. This helped aid us in our peer debriefing discussions.

Rationale for study location and population

According to the latest data,⁴⁵ the South continues to have the highest percentage of LGBTQ+ people. Data show nearly 36% of the nation’s adult LGBTQ+ population lives in the South, representing more than 5 million individuals. Despite the South being home to one in three LGBTQ people, having among the most racially and ethnically diverse populations, and communities ranging from some of the largest cities in the United States to many rural enclaves,⁴⁵ the Southern region of the United States currently has the most hostile policy climate for LGBTQ residents; the South has fewer positive LGBTQ laws than any other region and more harmful laws than any other.^46,47 Although racism is pervasive in all parts of the United States, the South’s history of slavery,⁴⁸ lynching,⁴⁹ and racism⁵⁰ perpetuates systemic and personal racism in all of life arenas, including in health care.⁵¹

Just over half of Black LGBT adults live in the US South,⁵² and in reality, race is a key factor that defines the US population’s health, economic state, and freedom.⁴⁵ If we are to understand health disparities in groups that have been oppressed on multiple levels, such as LGBT African Americans, we have to begin by recognizing and acknowledging the existence of multiple intersecting identities.⁵³ A study on LGBT well-being at the intersection of race assessed whether LGBT people of color differ from white LGBT people in several areas of socioeconomic well-being and health.⁵⁴ In terms of socioeconomic well-being, many key differences were identified, including that more Black LGBT adults experienced economic insecurity, a higher percentage had a household income of less than $25,000, were more likely to be unemployed, and experience food insecurity (especially pronounced in Black LGBT women), a higher percentage experienced food insecurity, and higher percent living in low-income households (even higher percent among Black LGBT women). A higher percentage of Black LGBT experienced significant financial stress, with almost ¾ not having sufficient money to make ends meet, nearly ½ having experienced a major economic crisis, and ¼ were laid off from a job in the past year. Differences between Black LGBT and white LGBT were also found on several key health indicators including a higher percentage of Black LGBT being diagnosed with depression (even higher percentage among Black LGBT women) and significantly greater odds of being diagnosed with serious health conditions. In terms of access to care, Black LGBT women are more likely not to have health insurance; more Black LGBT individuals have Medicaid as their primary insurance. LGBT adults reported being worried that their sexual orientation or gender identity would affect the quality of health care they received. Although both Black and White LGBT reported experiences with everyday discrimination, a slightly higher percentage of Black adults reported experiencing this. A large proportion of Black LGBT adults also reported experiencing victimization, including 60% reported being threatened with violence (44% had been physically or sexually assaulted, and 43% experienced robbery or destruction of property). The Black LGBT sub-population was found to be more in need of or impacted by policy and service interventions.⁵⁴

Results

The thematic analysis of 18 participants’ responses revealed 7 recurring themes and 3 sub-themes, as represented in Table 1. These themes encompassed various aspects of health care delivery, including initial interaction, collaboration with patients, effective communication, extended patient–physician time, equitable treatment, training on bedside manner and self-awareness, and addressing disparities within the health care system. Tables 2–4 present quotes from each of the specific recommendations from the participants. The following are descriptions and discussion of these themes, providing illustrative quotes from our participants.

Table 1.

Recommendations for Health Care System

Themes	Sub-Themes
1. Importance of Inclusivity, Starting at Initial Interaction
2. Be Willing to Collaborate with Patient
3. Physician and Caregiver Being Able to Spend More Time with the Patient
4. Effective Communication in Health Care	Thorough Explanation of the Medical Process
	Speak to Everyone in the Room
	Patient and Accessible Communication
5. Treat Each Person Equitably
6. Emphasize Good Bedside Manner and Self-Awareness at the Training Level
7. Bridge the Gap of Disparities

Table 2.

Themes 1 Through 3

Themes	White participants	African American participants
Importance of Inclusivity, Starting at Initial Interaction	“Some way to put that in the forms or something where you’re like, ‘I don’t really need that.’”“…the intake form. If you have choices and options that pertain to a wider demographic, rather than the heterocentric demographic, it makes the form a more welcoming, honest experience.”	“We’ve got to be more intentional about teaching people how to be inclusive. But on the flip side, though, there has to be consequences if you’re not going to be inclusive. No, you don’t have to treat gay people. But you know what? You’re not gonna be able to accept Medicare, Medicaid, and Aetna health insurance.”“I wrote a whole long thing about the nurse, to—everybody was joking. They were like, ‘You wrote a whole ‘nother dissertation about how to deal with her.’ And, I said, ‘You have implicit bias.’ I was like, ‘And there’s training for that and if you can’t get the training for that, then maybe this isn’t the right job for you because you’re not goin’ to be able to treat people who look like you and who have the same relationship that you have.’ I think it was a lot of teaching moments because again, remember, we are in rural south <State>. And this is where all of this is unfolding.”
Be Willing to Collaborate with Patient	“I wanna be heard and for the doctor to acknowledge that I know what the hell I’m talkin’ about. I don’t have a medical degree, but I know me better than you will ever know me. It’s very important, for me, for <Name> to be included in these discussions and treat her as you would treat me.”“…it all comes from attitude, and it comes from, ‘Okay, I’m a human being like you. I’ve done a lot of research. I’ve done a lot of training. I have a lot of experience as a surgeon or a physician or whatever. Based on my experience, this is—’ coming from that mindset rather than, ‘I know best.’ ‘Cause sometimes they don’t know best.”	“I had surgery about 15 years ago, and I got three opinions, and each doctor recommended the type of surgery that that doctor specialized in. It would be really nice to have them tell you the different types and why they specialize in this, and why they recommend this type. Not just it’s what I do and what I’ve always done.”“…she was a little bit more aggressive. I consider my personality more of an introvert. I’m like, ‘Oh, okay, okay.' But she’s more of an extrovert, so I just got up to say, 'I know she’s gonna take care of me.’ I don’t take that for granted, but humbly sayin’ I love her. She loves me, that she’s gonna take care. So I just kinda like, ‘Look, y’all listen to her.’”
Physician and Caregiver Being Able to Spend More Time with the Patient	“…to say to both of us, ‘Do you have any questions?’ But not to have it necessarily be the last thing as their seat is rising from the chair. [Laughter] To either have it be earlier in the visit or, I’m sitting here. I’m still present. But to ask both of us because sometimes our perspectives of what we want to understand are not identical, and I think when we both feel like we’re acknowledged, it’s important.”“And then I’m also hearing, potentially this general permission to dialogue, if you have any questions- along the way. I’m not gonna dump a bunch of information on you, and then, as I’m leaving, be like, ‘Any questions? No? No?’”	“…once my sister moved my mother to a different physician, communication was 180 degrees. The second physician actually found issues and discussed the lab work that the previous doctor had done and some issues that were in the lab work. I just feel very fortunate that there was someone there that could hear and realize that she wasn’t gettin’ the care that she needed and moved her to a physician that would. This was a positive outcome to move her. It was just really a feelin’ of relief to know that someone else was payin’ attention and bein’ attentive and not just writin’ her off.”“Let the nurses know, because the nurses are generally very good about saying, ‘Hey, yes, the doctor called and said she’s gonna be late. She has to make rounds, there’s an emergency on the other side of the hospital. She’s gonna get back to you as soon as she possibly can. The test came back. Everything looks good,’ or whatever it is that they can tell us. Be impeccable with your words. Show up, do what it is that you say you’re gonna do, understand that if you’re being impeccable with your word, everything else is gonna fall into place.”

Table 3.

Theme 4: Effective Communication in Health Care

Sub-Themes	White participants	African American participants
Thorough Explanation of the Medical Process	“If you have a serious illness, it really helps to have your partner, your life partner with you in the room during all of the discussions because I don’t know about you, but if somethin’ is said to me, it’s like kinda shocking, and it’s like you’re still in the shock of like, ‘What? What? What? What? What?’ And you’re not hearing everything else that your partner might be able to hear who could also be in shock as well, but not their body. So it really helps to have another person in the room and to ask for the other person to be in the room. I mean, of course, someone might say, ‘No, I don’t want her to know,’ but I would think, 9 times out of 10 if you’ve got a supportive relationship, that you will want her to be in there with you. So remembering that, remembering that for you, as the doctor, you’ve said these things so many times to so many patients, but for these people, it may be the very first time they’re hearing it, and so to remember that and treat them as human beings who have feelings and fears, et cetera.”“…be advised of what my options are. It’s like, ‘okay this is the problem. These are your options.’ Don’t just give me one option ‘cause it works best for you. You’re a surgeon, ergo, you want to do surgery on me. Let me know what other avenues I have to choose from because, ultimately, it’s my body. It’s my choice.”	“I think it is important and imperative that doctors, nurses, whomever listen to the family or to whomever the people are there to help you kind of figure out what this person is like.”“Always do your best. Show up for each patient as though this was the most important patient in the world because to the people in the room, it is. Be impeccable with your word, if you say you’re gonna do something and you get caught up—emergencies happen, it’s a hospital.”
Speak to Everyone in the Room	“ She is a part of me. Don’t treat her as just some appendage in the seat next to me.”“Acknowledge both people in the room. Allow for multiple perspectives, knowing that different questions might be coming from each of you as a patient, as a partner.”	“It needs to be more time spent, more questions asked, or ask the one that’s getting the care because it’s not all about the one laying in the bed. We have to go back home and treat them, your professionalism, you should be the one asking me or whomever, this, that and the third. Don’t just turn me off—that’s a whole ‘nother story. I ain’t taking no BS off of ‘em. I’m not. I talk to her boss, his boss, their boss, all the bosses.”“I think doctors and nurses need to be intentional with family, or whoever is there with the patient to say, ‘Hey, something doesn’t seem right,’ or, ‘Something is wrong. This is not their usual outlook. This is not what they do.’ And then the next day, when my mom was completely different, they were like, ‘Oh, God. I’m glad we heard you.’”
Patient and Accessible Communication	“… tell me the truth. Tell me what’s going on. I was hospitalized years ago for an emergency surgery, and I’d been in the hospital for three days before one of the nurses came over and said, “Did you know you almost died? Do you know how close you were to dying? Did you know we had to give you 12 units of blood?” Like, no, I had no idea what happened for three days. The docs came at times. I had no idea what was going on. So tell me the truth. [Laughter] A lot of times, they’ll tell the family, and they won’t tell the patient.”“…relatability and the communication skills between them and the people that they’re treating would be probably number one.”	“I would say that communication thing, I hold people to the standard of the four agreements. Don’t take things personally. If you’re arguing with the doctor or nurse, they should be professional enough to understand you’re grieving. Whether the person is still alive or not, you’re grieving, there’s a loss that’s happening. Doctors and nurses are trained for that. Especially doctors don’t always act as if. Don’t take things personally when somebody comes at you, don’t, ‘I’m not gonna deal with them because I don’t like the way they talk.’ Get over it. This is your job. You’re getting paid a lotta money to do it, you trained a lotta years to do it, to show up. Don’t take things personally. Don’t make assumptions. Don’t assume that because it’s a Black woman that they’re not gonna know something, or because of the way we look, or because of the way we talk, or because of our accents, that we’re uneducated. Don’t make that assumption.”“What was the most important thing for me, it would have to be communication and some patience. Because if you’re sick or your spouse is sick and you have questions, I want the practitioner to have the patience to go over those things with me. And if I don’t understand them, I’m gonna need you to go over it again or break it down so that I’m comfortable. I mean, ‘cause a lot of times, you can go into an appointment and they’ve got, I don’t know, 10 min blocked out for you. I don’t wanna feel like I’m being rushed out of the door. And I think particularly, if someone is very ill and you come into the room, I don’t want to see you trying to get out of the room before I’m comfortable with the diagnosis, prognosis going forward with treatment. So patience and communication for me is very important.”

Table 4.

Themes 5 Through 7

Themes	White participants	African American participants
Treat Each Person Equitably	“…listening, asking questions, giving us time to answer questions or ask questions. It goes without saying acknowledging who we are to each other, and we talked about that several times. I like the holistic, when you brought up the holistic, not just, ‘Here’s what the scans show, and here’s what your values are, and here’s what your tumor marker is,’ but, ‘How are you feeling today?” That will elicit a different response, often than not, ‘How are you feeling?’ versus, ‘Well, let’s talk about the good parts of your visit,’ or maybe the, ‘Here’s what’s good in your science and your scans, and here’s what’s not so good, and let’s do an exam,’ but ‘how are you feeling about where we are, where you are?’”“Don’t treat me like a woman. Don’t treat me differently because we’re a same-sex couple. I’m just another human being, and you’re a professional I’ve come to seek help from.”	“…compassionate, and also, being more attentive to the person who’s giving the care of the one that’s in the hospital. Ask us what we wanna do, or how we can make this better. It’s so like we’re on the sidelines and they’re not listening. I agree with her about listening and compassion. Also, professionalism, ‘cause you’re in the medical area, and you need to make sure this client, I hate to say patient, is lying there, and you need to make sure you’re on point with it. Don’t be side stepping with me. They do that a lot. It just ticks me off big time.”“…so it really kind of concerned me to this very day that I was on the level of my career as an officer and things of that nature. And sometimes when people hear that you’re so ambitious from other races, other things, they find certain ways to do certain things to cut that short. I scratch my head on [that] a lot.”
Emphasize Good Bedside Manner and Self-Awareness at the Training Level	“They can go out in the hall and talk to these students. But while you’re in my room, you’re gonna talk to me, or you can leave.”“I’m thinking of some things that I’ve participated in where white privilege was being described. I think of myself as a pretty okay person and accepting and whatnot, but they supplied just little quick vignettes of situations that seemed kind of normal to me, but, in fact, were an expression of my white privilege. I didn’t think of ‘em as that. I thought of ‘em as kind of normal. And so, perhaps, some very simple examples of here’s where you may be alienating the person of a different sexuality than your own that you might not even realize.”	“That’s what I don’t like in the medical field. Don’t cut no corners. Address it as it is. Show your professionalism, show your compassion. That’s what you’re trained for. That’s what you went to college for. Show that you’re interested in what’s going on, instead of all this backlash. Instead of handling it head on. I don’t like the way you’re talking to her, or I don’t agree with it. So many people get caught up that they don’t say nothing, ‘cause I’m the type of person, I’m gonna call you when I see it. When you’re caring for a loved one and you’re over her care, and you got that uniform on queen, I’ve got something for you. I’m gonna bring it to you. I don’t care who doesn’t like it. I’m gonna question you. If I can’t get the question from you, I’m going higher than you and if I can’t get the question from them, I’m going higher than them as well. I go up that ladder, ‘cause I’m not tolerating no nothing about my loved ones. Been there, done that. I know it’s a chain of command, and I’ll use it to my best advantage.”“I think people in the medical industry are gonna have to start being sensitive to the changing demographics that they’re dealing with. It’s basically our whole theme here. We have different needs, and I think those diverse needs start back in medical school or nursing school or social work, to start dealing with this community. One of the things, you go to the doctor and they may or may not ask your sexual preference. I think given that they may not know, would depend on how they treat you. Since I’ve been here in this study, my whole response has been communication, communication, communication. You gotta be able to listen. You need to be able to hear them. Then when you hear them, the medical professional needs to be able to say, or respond in a way that lets the patient know that I hear you and I respect what you’re saying. Just like members here have all said, ‘I’ve told them what I wanted, it went right over their heads and they kept moving on.’ Training professionals to listen and respond. The wishes of a patient, particularly when they’re critically ill, is more important, I think, than anything.”
Bridge the Gap of Disparities	“…do more studies with women of all different ages and so that you can see what side effects of different drugs are for different demographics.”“Believing us when we say what’s goin’ on with us, not discrediting or discounting saying, ‘Oh, no, no, it’s not that. It’s not that.’ If you’re saying you’ve got something… for the longest time, <Name> was complaining about gut issues.”	“Someone said starting from the basics, setting a solid foundation. I think a part of that needs to be making sure rural doctors have the same access or same level of care as far as the basics as a doctor in the urban area. Then even when that technology is available, which we all know it’s available, will they use it.”“I think that our voices are missing from the journals, and our voices are missing in the research.”

Importance of inclusivity, starting at initial interaction

The analysis revealed that an inclusive health care environment, beginning with the initial interaction, is crucial for providing quality care to older LB women. Participants emphasized the need for health care professionals to demonstrate respect, cultural sensitivity, and recognition of diverse identities. The establishment of trust and cooperation was seen as vital in fostering effective patient–provider relationships.

Be willing to collaborate with patient

Collaboration between health care professionals and older lesbian and bisexual women emerged as a key element in improving health care outcomes. Participants emphasized the importance of involving patients in decision-making processes and tailoring treatment plans to their specific needs and preferences. Active collaboration was seen as promoting patient empowerment and improving treatment adherence.

Physician and caregiver being able to spend more time with the patient

Participants expressed the importance of health care professionals having sufficient time to engage with older lesbian and bisexual women. Extended appointment times were seen as crucial for building rapport, understanding patients’ medical histories, and addressing their emotional and psychological needs. This theme highlighted the significance of allocating adequate time for comprehensive care delivery.

Effective communication in health care

Participants discussed the importance of effective communication and described what that looks like through the sub-themes identified.

The first is a Thorough Explanation of the Medical Process, where participants highlighted the significance of health care professionals offering thorough explanations of diagnoses, treatment options, and potential side effects. Clear and comprehensive communication was essential in ensuring patients’ understanding, facilitating informed decision-making, and enabling active participation in their health care journey.

They also suggested clinicians Speak to Everyone in the Room, speaking to the importance of health care professionals addressing not only the patient but also their partners, family members, and caregivers. Participants emphasized the need for inclusive language and involving everyone present in discussions and decision-making processes. This approach fostered a sense of support and inclusivity within the health care setting.

Finally, participants suggested that the delivery of the information was important through Patient and Accessible Communication. Participants stressed the need for patient and accessible communication strategies to meet the diverse needs of LB older women. Health care practitioners were encouraged to use language that was clear, understandable, and culturally sensitive. The creation of safe spaces for open discussions and the active engagement of patients in their care were seen as vital components of effective communication.

Treat each person equitably

Participants emphasized the need for equitable treatment regardless of sexuality. They advocated for the elimination of biases and prejudices within health care settings, promoting fair and unbiased care for all patients. Treating each person equitably was viewed as a fundamental principle for improving the overall health care experiences of LB older women.

Emphasize good bedside manner and self-awareness at the training level

Participants highlighted the importance of health care professionals receiving training on good bedside manner and self-awareness. This training was seen as essential for fostering empathy, cultural competence, and sensitivity to the unique needs of LB older women. The emphasis on self-reflection and awareness aimed to address and minimize personal biases in health care interactions.

Bridge the gap of disparities

Participants emphasized the need to address disparities within the health care system to ensure equitable access and outcomes for LB older women. Collaborative efforts between health care professionals, policymakers, educators, and community leaders were recommended to develop targeted interventions and policies. The goal was to reduce barriers, improve access to care, and address the unique health care needs of this population.

Discussion

In the current health care landscape, calls for patient-centered care^16,55–57 that also incorporates cultural competence abound.⁵⁸ This approach to patient care underscores essential communication skills, awareness of overarching cultural and social issues, and universal health beliefs, necessitating the recognition and negotiation of diverse communication styles, decision-making preferences, family dynamics, and addressing issues like sexuality, gender, mistrust, prejudice, and racism.⁵⁹ This approach is also aligned with feedback given by participants in this current study who indicated the importance of knowing and honoring your audience and not making assumptions based on possible internalized stereotypes or previous interactions with other patients.

Available research indicates mixed findings in regard to LGBTQ+ patient comfort and encouragement in sharing with health care professionals.^60–64 A systematic review of patient needs and experiences in palliative care, including communication between clinicians and health care professionals, indicates culturally competent communication significantly influenced patients’ feelings that their beliefs, experiences, and preferences were welcomed by the professionals. This indicated that clinician behavior was influential in either impeding or enhancing patient involvement, including disclosure of sexuality and gender identity in the consultation in terms of asking questions and sharing their perspectives.²

LGBTQ+ health disparities

It is well known that LGBTQ+ patients globally face disparities in care^1,2,7,65,66 such as heteronormative constructs, issues with disclosures, and challenges communicating with health care professionals who do not have adequate education or training in working with LGBTQ+ populations.⁶⁶ Our study identified several issues around equity, inclusivity, communication, collaboration, and self-awareness in clinicians that may enhance the quality of care and support for LB older women which mirror current experiences of these populations, in particular around intersectional identities.^4,67 The lack of a standard of care curated specifically for LB older women continues to affect the care experience of this patient population; thus, practicing mindfulness around the type of communication, the way partners and other chosen caregivers are included, and willingness to collaborate with patients is tantamount in creating a safe and patient-centered space for LB older women patients.

Because this population has experienced care tailored traditionally to a cisgender, heteronormative White population, it is not unexpected they may approach interactions with health care professionals with a degree of skepticism. Our findings reflect previous research suggesting inclusivity should originate at the first encounter and clinicians should develop strategies based on cultural humility to address issues around discrimination, implicit bias, and stigmatization of diverse LGBTQ+ patient populations.¹² Health care professionals should strive to create an environment of safety, trust, respect, and cooperation and must include chosen care partners during the initial visit. Prior findings indicate that health care professionals struggle with knowing how to initiate a conversation around sexuality or gender identity,⁷ and this issue is also evidenced in our study; however, providing training and education around creating an inclusive environment for LGB older adult patients may help alleviate some of those concerns.^7,12 Consistent with prior studies, participants felt less invisible when their clinicians made time to engage and acknowledge patients’ decision-making to empower the patient and their chosen care partners as well as made time to know them as a patient with needs related to identifying as a lesbian or bisexual older woman.⁶⁸

Inclusion of African American voices

African American LB older women participants provided a further voice to previously identified barriers around patient–clinician communication, collaboration, and decision-making.⁶⁹ Our findings also support previous literature positing that multiple social identities (e.g., race, sexuality, gender identity, education, and socioeconomics) overlap within an individual’s lived experience, reflecting compounding, interconnected areas of both privilege and oppression at the social-structural level including racism.⁵³ In health care interactions, our participants identified that being African American, older, and female may have affected the information they were given, whether the issues they voiced were believed, and whether their decisions and requests were honored. These findings mirror those found in previous literature on perceived discrimination from health care professionals around avoidance of traditional health care environments based on perceived discrimination by health care professionals.⁷⁰

The findings of the current study support previous literature encouraging the inclusion of historically excluded voices in health care⁷¹ underscoring the importance of patient-centered care that is culturally relevant to all patients. Our Black participants’ recommendations on increasing the number of medical professionals who represent them in race, ethnicity, sexuality, gender identity, and culture also support research emphasizing more professional intersectional representation in multiple areas of medicine, including both clinical environments and research.⁷² This also underscores research noting a need to increase the number of Black individuals who participate in clinical research so the default knowledge of medicine isn’t based on White bodies.⁷³

Health equity implications

The findings of this thematic analysis underscore the importance of promoting inclusive health care practices for LB older women. By recognizing the significance of inclusivity, collaboration, effective communication, extended patient–physician time, equitable treatment, bedside manner, self-awareness, and addressing disparities, health care systems can enhance the quality of care and support for this underrepresented population. Implementing these findings into clinical practice and policy development can foster inclusive health care environments that meet the unique needs of LB older women, leading to improved health outcomes and overall patient satisfaction.

Footnotes

Acknowledgment

The authors would like to acknowledge the invaluable contribution of their Community Advisory Board and all focus group members; the authors could not have done this project without them.

Authors’ Contributions

S.L.: Co-PI of study, wrote introduction, wrote methods, analyzed data, wrote results, contributed to results and implications, and wrote conclusion. K.V.: wrote introduction, wrote methods, contributed to results and implications, and edited the article. R.E.: Co-PI of study and mentored project and the article.

Ethical Approval

This study was approved by the Institutional Review Board at the University of Alabama at Birmingham (IRB-300004696), and all data were deidentified. All participants gave written informed consent to participate in the study and provided written consent prior to focus group interviews.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This project was made possible by the funding provided by the Palliative Research Enhancement Project at the University of Alabama at Birmingham.

Abbreviations Used

References

Cloyes

, Hull

, Davis

. Palliative and end-of-life care for Lesbian, Gay, Bisexual, and Transgender (LGBT) cancer patients and their caregivers. Semin Oncol Nurs, 2018; 34(1):60–71; doi: 10.1016/j.soncn.2017.12.003

Rosa

, Roberts

, Braybrook

, et al. Palliative and end-of-life care needs, experiences, and preferences of lgbtq+ individuals with serious illness: A systematic mixed-methods review. Palliat Med, 2023; 37(4):460–474; doi: 10.1177/02692163221124426

Moagi

, van Der Wath

, Jiyane

, et al. Mental health challenges of lesbian, gay, bisexual and transgender people: An integrated literature review. Health SA, 2021; 26:1487; doi: 10.4102/hsag.v26i0.1487

Funk

. Black Americans’ views about health disparities, experiences with health care. 2024. Available from: https://www.pewresearch.org/science/2022/04/07/black-americans-views-about-health-disparities-experiences-with-health-care/

Javier

. Palliative care needs, concerns, and affirmative strategies for the LGBTQ population. Palliat Care Soc Pract, 2021; 15:26323524211039234; doi: 10.1177/26323524211039234

Tan

, Waters

, Chen

, et al. Inequities among cancer caregivers with diverse identities: A review of the literature and future directions. Curr Oncol Rep, 2023; 25(7):803–812; doi: 10.1007/s11912-023-01415-3

Valenti

, Bybee

, Nwakasi

, et al. Palliative care professionals’ perceptions of communication with sexual and gender minority patients. Am J Hosp Palliat Care, 2023; 41(7):771–785; doi: 10.1177/10499091231212666

Furness

, Goldhammer

, Montalvo

, et al. Transforming primary care for lesbian, gay, bisexual, and transgender people: A collaborative quality improvement initiative. Ann Fam Med, 2020; 18(4):292–302; doi: 10.1370/afm.2542

Lenko

, Hoffman

, Robinson-Lane

, et al. Achieving goal-concordant care: Formal and informal advance care planning for white, Black, and Hispanic older adults. J Am Geriatr Soc, 2024; 72(8):2412–2422; doi: 10.1111/jgs.18971

10.

Sanders

, Curtis

, Tulsky

. Achieving goal-concordant care: A conceptual model and approach to measuring serious illness communication and its impact. J Palliat Med, 2018; 21(S2):S17–S27; doi: 10.1089/jpm.2017.0459

11.

Braybrook

, Bristowe

, Timmins

, et al. Communication about sexual orientation and gender between clinicians, LGBT+ people facing serious illness and their significant others: A qualitative interview study of experiences, preferences and recommendations. BMJ Qual Saf, 2023; 32(2):109–120; doi: 10.1136/bmjqs-2022-014792

12.

Prasad

, O’Malley

, DeLeon

, et al. Inclusive LGBTQIA+ healthcare: An interprofessional case-based experience for cultural competency awareness. Front Public Health, 2022; 10:993461; doi: 10.3389/fpubh.2022.993461

13.

Bass

, Nagy

. Cultural Competence in the Care of LGBTQ Patients. Statpearls. StatPearls Publishing; 2023.

14.

Chan

, Henesy

. Navigating intersectional approaches, methods, and interdisciplinarity to health equity in LGBTQ+ communities. J LGBT Issues Couns, 2018; 12(4):230–247; doi: 10.1080/15538605.2018.1526157

15.

Castro

, Van Regenmortel

, Vanhaecht

, et al. Patient empowerment, patient participation and patient-centeredness in hospital care: A concept analysis based on a literature review. Patient Educ Couns, 2016; 99(12):1923–1939; doi: 10.1016/j.pec.2016.07.026

16.

Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm:A New Health System for The 21st Century. 2001.

17.

Brown

, Marshall

, Snyder

, et al. Perspectives about racism and patient-clinician communication among black adults with serious illness. JAMA Netw Open, 2023; 6(7):e2321746-e2321746; doi: 10.1001/jamanetworkopen.2023.21746

18.

Agarwal

, Gonzales

, Sagan

, et al. Perspectives of black patients on racism within emergency care. JAMA Health Forum, 2024; 5(3):e240046-e240046; doi: 10.1001/jamahealthforum.2024.0046

19.

Riggan

, Rousseau

, Halyard

, et al. “There’s not enough studies”: Views of black breast and ovarian cancer patients on research participation. Cancer Med, 2023; 12(7):8767–8776; doi: 10.1002/cam4.5622

20.

Chambers

, Taylor

, Nelson

, et al. Clinicians’ perspectives on racism and black women’s maternal health. Womens Health Rep (New Rochelle), 2022; 3(1):476–482; doi: 10.1089/whr.2021.0148

21.

Martin

, Johnson

. You can’t dismantle what you don’t recognize: The effect of learning critical black history in healthcare on perspective-taking. J Exp Psychol Gen, 2024; 153(11):2631–2641; doi: 10.1037/xge0001482

22.

Adebayo

, Parcell

, Mkandawire-Valhmu

, et al. African American women’s maternal healthcare experiences: A critical race theory perspective. Health Commun, 2022; 37(9):1135–1146; doi: 10.1080/10410236.2021.1888453

23.

Greene

, Tuzzio

, Cherkin

. A framework for making patient-centered care front and center. Perm J, 2012; 16(3):49–53; doi: 10.7812/tpp/12-025

24.

Légaré

, Thompson-Leduc

. Twelve myths about shared decision making. Patient Educ Couns, 2014; 96(3):281–286; doi: 10.1016/j.pec.2014.06.014

25.

Stiggelbout

, Van der Weijden

, De Wit

, et al. Shared decision making: Really putting patients at the centre of healthcare. BMJ, 2012; 344:e256; doi: 10.1136/bmj.e256

26.

. Intersectionality and shared decision making in lgbtq health. LGBT Health, 2016; 3(5):325–326; doi: 10.1089/lgbt.2016.0115

27.

Montero

, Hamel

, Artiga

. L D. Lgbt adults’ experiences with discrimination and health care disparities: Findings from the kff survey of racism, discrimination, and health. 2024. Available from: https://www.kff.org/report-section/lgbt-adults-experiences-with-discrimination-and-health-care-disparities-findings/

28.

Bastemeijer

, Voogt

, van Ewijk

, et al. What do patient values and preferences mean? A taxonomy based on a systematic review of qualitative papers. Patient Educ Couns, 2017; 100(5):871–881; doi: 10.1016/j.pec.2016.12.019

29.

O’Hare

, Richards

, Szarka

, et al. Emotional impact of illness and care on patients with advanced kidney disease. Clin J Am Soc Nephrol, 2018; 13(7):1022–1029; doi: 10.2215/cjn.14261217

30.

Kang

, Stenfors-Hayes

. Feeling well and having good numbers: Renal patients’ encounter with clinical uncertainties and the responsibility to “live well. Qual Health Res, 2016; 26(12):1591–1602; doi: 10.1177/1049732315591484

31.

Zoffmann

, Harder

, Kirkevold

. A person-centered communication and reflection model: Sharing decision-making in chronic care. Qual Health Res, 2008; 18(5):670–685; doi: 10.1177/1049732307311008

32.

Ubel

. Medical facts versus value judgments–toward preference-sensitive guidelines. N Engl J Med, 2015; 372(26):2475–2477; doi: 10.1056/NEJMp1504245

33.

Mulley

, Trimble

, Elwyn

. Stop the silent misdiagnosis: Patients’ preferences matter. BMJ, 2012; 345:e6572; doi: 10.1136/bmj.e6572

34.

Wallerstein

, Duran

. Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. Am J Public Health, 2010; 100(Suppl 1):S40–S6; doi: 10.2105/ajph.2009.184036

35.

Laveaux

, Christopher

. Contextualizing cbpr: Key principles of cbpr meet the indigenous research context. Pimatisiwin, 2009; 7(1):1.

36.

Halcomb

, Gholizadeh

, DiGiacomo

, et al. Literature review: Considerations in undertaking focus group research with culturally and linguistically diverse groups. J Clin Nurs, 2007; 16(6):1000–1011; doi: 10.1111/j.1365-2702.2006.01760.x

37.

Reisner

, Randazzo

, White Hughto

, et al. Sensitive health topics with underserved patient populations: Methodological considerations for online focus group discussions. Qual Health Res, 2018; 28(10):1658–1673; doi: 10.1177/1049732317705355

38.

Braun

, Clarke

. Supporting best practice in reflexive thematic analysis reporting in palliative medicine: A review of published research and introduction to the reflexive thematic analysis reporting guidelines (rtarg). Palliat Med, 2024; 38(6):608–616; doi: 10.1177/02692163241234800

39.

Vaismoradi

, Snelgrove

. Theme in qualitative content analysis and thematic analysis. Forum: Qualitative Social Research, 2019; 20(3); doi: 10.17169/fqs-20.3.3376

40.

Morrow

. Quality and trustworthiness in qualitative research in counseling psychology. J Couns Psychol, 2005; 52(2):250–260; doi: 10.1037/0022-0167.52.2.250

41.

Lincoln

, Guba

. Naturalistic Inquiry. Sage; 1985.

42.

Erlandson

, Harris

, Skipper

, et al. Doing Naturalistic Inquiry: A Guide to Methods. Sage Publications; 1993.

43.

Morse

. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res, 2015; 25(9):1212–1222; doi: 10.1177/1049732315588501

44.

Shenton

. Strategies for ensuring trustworthiness in qualitative research projects. EFI, 2004; 22(2):63–75; doi: 10.3233/EFI-2004-22201

45.

Flores

, Conron

. Adult lgbt population in the united states. 2023.

46.

Movement Advancement Project. Alabama’s equality profile. 2023. Available from: https://www.lgbtmap.org/equality_maps/profile_state/AL [Last accessed: August 7, 2023].

47.

Movement Advancement Project. Lgbtq policy spotlight: Mapping lgbtq equality in the u.S. South. 2020. Available from: www.lgbtmap.org/regional-south-tally

48.

Acharya

, Blackwell

. M S. Deep Roots: How Slavery Still Shapes Southern Politics. Princeton University Press; 2018.

49.

Kihlström

, Kirby

. We carry history within us: Anti-black racism and the legacy of lynchings on life expectancy in the u.S. South. Health Place /2021; 70:102618; doi: 10.1016/j.healthplace.2021.102618

50.

Allison

, Chaney

, CM

. Racism and inequality in the deep south: The health and sociocultural correlates of hiv/aids among african americans and the legacy of slavery. In: A

, ed. Handbook of Racism, Xenophobia, and Populism. Springer; 2022.

51.

Volpe

, Schorpp

, Cacace

, et al. State- and provider-level racism and health care in the u.S. Am J Prev Med, 2021; 61(3):338–347; doi: 10.1016/j.amepre.2021.03.008

52.

Walsh

. “It really is not just gay, but african american gay”: The impact of community and church on the experiences of black lesbians living in north central florida. J Homosex, 2016; 63(9):1236–1252; doi: 10.1080/00918369.2016.1151694

53.

Elk

. The intersection of racism, discrimination, bias, and homophobia toward african american sexual minority patients with cancer within the health care system. Cancer, 2021; 127(19):3500–3504; doi: 10.1002/cncr.33627

54.

Choi

, Wb , Mallory

. Black lgbt adults in the us: Lgbt well-being at the intersection of race. 2021. Available from: https://williamsinstitute.law.ucla.edu/publications/black-lgbt-adults-in-the-us/

55.

Kennedy

, Rehman

, Johnson

, et al. Healthcare providers versus patients’ understanding of health beliefs and values. Patient Exp J, 2017; 4(3):29–37.

56.

Kuipers

, Cramm

, Nieboer

. The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Serv Res, 2019; 19(1):13; doi: 10.1186/s12913-018-3818-y

57.

Santana

, Manalili

, Jolley

, et al. How to practice person-centred care: A conceptual framework. Health Expect, 2018; 21(2):429–440; doi: 10.1111/hex.12640

58.

Stubbe

. Practicing cultural competence and cultural humility in the care of diverse patients. Focus (Am Psychiatr Publ), 2020; 18(1):49–51; doi: 10.1176/appi.focus.20190041

59.

Epner

, Baile

. Patient-centered care: The key to cultural competence. Ann Oncol, 2012; 23 (Suppl 3):33–42; doi: 10.1093/annonc/mds086

60.

Patterson

, Jabson Tree

, Kamen

. Cultural competency and microaggressions in the provision of care to lgbt patients in rural and appalachian tennessee. Patient Educ Couns, 2019; 102(11):2081–2090; doi: 10.1016/j.pec.2019.06.003

61.

Bernacki

, Block

, American College of Physicians High Value Care Task Force. Communication about serious illness care goals: A review and synthesis of best practices. JAMA Intern Med, 2014; 174(12):1994–2003; doi: 10.1001/jamainternmed.2014.5271

62.

Timmins

, Rimes

, Rahman

. Minority stressors, rumination, and psychological distress in lesbian, gay, and bisexual individuals. Arch Sex Behav, 2020; 49(2):661–680; doi: 10.1007/s10508-019-01502-2

63.

Toze

, Fish

, Hafford-Letchfield

, et al. Applying a capabilities approach to understanding older lgbt people’s disclosures of identity in community primary care. Int J Environ Res Public Health, 2020; 17(20); doi: 10.3390/ijerph17207614

64.

Whitehead

, Shaver

, Stephenson

. Outness, stigma, and primary health care utilization among rural lgbt populations. PLoS One, 2016; 11(1):e0146139; doi: 10.1371/journal.pone.0146139

65.

Stein

, Berkman

, Acquaviva

, et al. Project respect: Experiences of seriously ill lgbtq+ patients and partners with their health care providers. Health Aff Sch, 2023; 1(4):qxad049; doi: 10.1093/haschl/qxad049

66.

Campbell

, Nathoo

, Chard

, et al. Lesbian, gay, bisexual, transgender and or queer patient experiences in canadian primary care and emergency departments: A literature review. Cult Health Sex, 2023; 25(12):1707–1724; doi: 10.1080/13691058.2023.2176548

67.

Moreno

, Belhouari

, Dussault

. A systematic literature review of the impact of covid-19 on the health of lgbtqia+ older adults: Identification of risk and protective health factors and development of a model of health and disease. J Homosex, 2024; 71(5):1297–1331; doi: 10.1080/00918369.2023.2169851

68.

Henriquez

, Ahmad

. “The message is you don’t exist”: Exploring lived experiences of rural lesbian, gay, bisexual, transgender, queer/questioning (lgbtq) people utilizing health care services. SAGE Open Nurs, 2021; 7:23779608211051174; doi: 10.1177/23779608211051174

69.

Wilson

, Yoshikawa

. Improving access to health care among African-American, Asian and pacific islander, and latino lesbian, gay, and bisexual populations. In: The Health of Sexual Minorities: Public Health Perspectives on Lesbian, Gay, Bisexual, and Transgender Populations. Springer Science + Business Media; 2007:607–637.

70.

Macias-Konstantopoulos

, Collins

, Diaz

, et al. Race, healthcare, and health disparities: A critical review and recommendations for advancing health equity. West J Emerg Med, 2023; 24(5):906–918; doi: 10.5811/westjem.58408

71.

Haboush-Deloye

, Marquez

, Dunne

, et al. Nevada Minority Health and Equity Coalition. The importance of community voice: Using community-based participatory research to understand the experiences of African American, Native American, and Latinx people during a pandemic. Prev Chronic Dis, 2023; 20:E12; doi: 10.5888/pcd20.220152

72.

Levites Strekalova

, Qin

, Sharma

, et al. The black voices in research curriculum to promote diversity and inclusive excellence in biomedical research. J Clin Transl Sci, 2021; 5(1):e206; doi: 10.1017/cts.2021.869

73.

Awidi

, Al Hadidi

. Participation of black americans in cancer clinical trials: Current challenges and proposed solutions. JCO Oncol Pract, 2021; 17(5):265–271; doi: 10.1200/op.21.00001

Enhancing Health Care Experiences for Racially Diverse,Lesbian,and Bisexual Older Women: Insights on Perceived Inclusivity and Equity