The present work experimentally examines how identity cues that signal minority inclusion contribute to sexual minorities’ (SM) healthcare visit expectations. We find that minority representation cues reduced SM’s (N = 188) expectations of a healthcare provider’s bias and increased perceived provider cultural competency which was, in turn, associated with lower anticipated identity-based devaluation and greater sexual orientation disclosure comfort. Providers’ diversity-valuing statements had mixed effects highlighting the importance of more concrete indicators of inclusion in this context. This work suggests that a lack of identity safety cues in healthcare settings may contribute to disparate health outcomes for sexual minority populations.
AbramsDHoggMA (eds) (1990) Social Identity Theory: Constructive and Critical Advances. Springer-Verlag Publishing.
2.
AlbujaAFSanchezDTLeeSJ, et al. (2019) The effect of paternal cues in prenatal care settings on men’s involvement intentions. PLoS One14(5): e0216454.
3.
ApfelbaumEPStephensNMReagansRE (2016). Beyond one-size-fits-all: Tailoring diversity approaches to the representation of social groups. Journal of Personality and Social Psychology111: 547–566.
4.
AronsonJBurgessDPhelanSM, et al. (2013) Unhealthy interactions: The role of stereotype threat in health disparities. American Journal of Public Health103(1): 50–56.
5.
AustinEL (2013) Sexual orientation disclosure to health care providers among urban and non-urban southern lesbians. Women & Health53(1): 41–55.
6.
BeehlerGP (2001) Confronting the culture of medicine: Gay men’s experiences with primary care physicians. Journal of the Gay and Lesbian Medical Association5(4): 135–141.
7.
BlosnichJRFarmerGWLeeJG, et al. (2014) Health inequalities among sexual minority adults: Evidence from ten US states, 2010. American Journal of Preventive Medicine46(4): 337–349.
8.
BrenickARomanoKKeglerC, et al. (2017). Understanding the influence of stigma and medical mistrust on engagement in routine healthcare among black women who have sex with women. LGBT Health4(1): 4–10.
9.
BuchmuellerTCarpenterCS (2010) Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. American Journal of Public Health; Washington100(3): 489–495.
10.
BurgessDJWarrenJPhelanS, et al. (2010) Stereotype threat and health disparities: What medical educators and future physicians need to know. Journal of General Internal Medicine25(2): 169–177.
11.
ButlerMMacCreedyESchwerN, et al. (2016). Improving cultural competence to reduce health disparities. Health Affairs24(2): 499–505.
12.
ChaneyKESanchezDT (2018) Gender-inclusive bathrooms signal fairness across identity dimensions. Social Psychological and Personality Science9(2): 245–253.
13.
CharltonBMCorlissHLMissmerSA, et al. (2011) Reproductive health screening disparities and sexual orientation in a cohort study of U.S. adolescent and young adult females. Journal of Adolescent Health49(6): 1241–1299.
14.
CipollinaRSanchezDT (2019) Reducing health care disparities through improving trust: An identity safety cues intervention for stigmatized groups. Translational Issues in Psychological Science5(4): 315–325.
15.
CipollinaRSanchezDT (2020) Racial identity safety cues and healthcare provider expectations. Stigma and Health. Epub ahead of print 10 September 2020. DOI: 10.1037/sah0000265.
16.
CliftJKirbyJ (2012). Health care access and perceptions of provider care among individuals in same-sex couples: Findings from the Medical Expenditure Panel Survey (MEPS). Journal of Homosexuality59: 839–850.
17.
CochranSDBjörkenstamCMaysVM (2016) Sexual orientation and all-cause mortality among US adults aged 18 to 59 years, 2001–2011. American Journal of Public Health106(5): 918–920.
18.
CohenLLSwimJK (1995) The differential impact of gender ratios on women and men: Tokenism, self-confidence, and expectations. Personality and Social Psychology Bulletin21(9): 876–884.
19.
CostaABPasePFde CamargoES, et al. (2016). Effectiveness of a multidimensional web-based intervention program to change Brazilian health practitioners’ attitudes toward the lesbian, gay, bisexual and transgender population. Journal of Health Psychology21(3): 356–368.
20.
DaviesPGSpencerSJSteeleCM (2005) Clearing the air: Identity safety moderates the effects of stereotype threat on women’s leadership aspirations. Journal of Personality and Social Psychology88(2): 276.
21.
DeanMAVictorEGuidry-GrimesL (2016) Inhospitable healthcare spaces: Why diversity training on LGBTQIA issues is not enough. Journal of Bioethical Inquiry13(4): 557–570.
22.
DovidioJFPennerLACalabreseSK, et al. (2017) Physical health disparities and stigma: Race, sexual orientation, and body weight. In: MajorBDovidioJFLinkBG (eds.) The Oxford Handbook of Stigma, Discrimination, and Health. New York, NY: Oxford University Press, pp.29–51.
23.
DursoLEMeyerIH (2013) Patterns and predictors of disclosure of sexual orientation to health care providers among lesbians, gay men, and bisexuals. Sexuality Research and Social Policy10: 35–42.
24.
EliasonMJSchopeR (2001) Does “don’t ask don’t tell” apply to health care? Lesbian, gay, and bisexual people’s disclosure to health care providers. Journal of the Gay and Lesbian Medical Association5(4): 125–134.
25.
FaulFErdfelderEBuchnerA, et al. (2009). Statistical power analyses using G* Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods41(4): 1149–1160.
26.
FingerhutAWAbdouCM (2017) The role of healthcare stereotype threat and social identity threat in LGB health disparities. Journal of Social Issues73(3): 493–507.
27.
FrostDMParsonsJTNanínJE (2007) Stigma, concealment and symptoms of depression as explanations for sexually transmitted infections among gay men. Journal of Health Psychology12(4): 636–640.
28.
GessnerMBishopMDMartosA, et al. (2019) Sexual minority people’s perspectives of sexual health care: Understanding minority stress in sexual health settings. Sexuality Research and Social Policy17: 607–618.
29.
GoodCInzlichtM (2006) How environments can threaten academic performance, self-knowledge, and sense of belonging. In: Stigma and Group Inequality. East Sussex: Psychology Press, pp.143–164.
30.
GruskinEPGreenwoodGLMateviaM, et al. (2007) Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California. American Journal of Public Health97(8): 1496–1502.
31.
HallWSchmaderTAdayA, et al. (2018) Climate control: The relationship between social identity threat and cues to an identity-safe culture. Journal of Personality and Social Psychology115(3): 446–467.
HatzenbuehlerML (2010) Social factors as determinants of mental health disparities in LGB populations: Implications for public policy. Social Issues and Policy Review4(1): 31–62.
34.
HatzenbuehlerMLPhelanJCLinkBG (2013) Stigma as a fundamental cause of population health inequalities. American Journal of Public Health103(5): 813–821.
35.
HeckJESellRLGorinSS (2006) Health care access among individuals involved in same-sex relationships. American Journal of Public Health96(6): 1111–1118.
36.
HuLTBentlerPM (1999) Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal6(1): 1–55.
37.
Institute of Medicine (2011) The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press.
38.
KlineRB (2011) Convergence of structural equation modeling and multilevel modeling. In:The SAGE Handbook of Innovation in Social Research Methods. SAGE, pp.562–589.
39.
LickDJDursoLEJohnsonKL (2013) Minority stress and physical health among sexual minorities. Perspectives on Psychological Science8(5): 521–548.
40.
MartosAJWilsonPAGordonAR, et al. (2018) “Like finding a unicorn”: Healthcare preferences among lesbian, gay, and bisexual people in the United States. Social Science & Medicine208: 126–133.
41.
MosackKEBrouwerAMPetrollA (2013) Sexual identity, identity disclosure, and health care experiences: Is there evidence for differential homophobia in primary care practice?Women’s Health Issues23: 341–360.
42.
MurphyMCSteeleCMGrossJJ (2007) Signaling threat: How situational cues affect women in math, science, and engineering settings. Psychological Science18(10): 879.
43.
MuthénLKMuthénBO (2017) Mplus: Statistical Analysis with Latent Variables: User’s Guide (Version 8). Los Angeles, CA: Authors.
44.
Nápoles-SpringerAMSantoyoJHoustonK, et al. (2005) Patients’ perceptions of cultural factors affecting the quality of their medical encounters. Health Expectations8(1): 4–17.
45.
PachankisJEHatzenbuehlerMLStarksTJ (2014) The influence of structural stigma and rejection sensitivity on young sexual minority men’s daily tobacco and alcohol use. Social Science & Medicine103: 67–75.
46.
PennerLAPhelanSMEarnshawV, et al. (2018) Patient stigma, medical interactions, and health care disparities: A selective review. In: MajorBDovidioJFLinkBG (eds.) Oxford Library of Psychology. The Oxford Handbook of Stigma, Discrimination, and Health. Oxford: Oxford University Press, pp.183–201.
47.
PetrollAEMosackKE (2011) Physician awareness of sexual orientation and preventive health recommendations to men who have sex with men. Sexually Transmitted Diseases38(1): 63–67.
48.
PolitiMCClarkMAArmstrongG, et al. (2009) Patient–provider communication about sexual health among unmarried middle-aged and older women. Journal of General Internal Medicine24(4): 511–516.
49.
PowellWRichmondJMohottigeD, et al. (2019) Medical mistrust, racism, and delays in preventive health screening among African-American men. Behavioral Medicine45(2): 102–117.
50.
Purdie-VaughnsVSteeleCMDaviesPG, et al. (2008) Social identity contingencies: How diversity cues signal threat or safety for African Americans in mainstream institutions. Journal of Personality and Social Psychology94(4): 615–630.
51.
QureshiRIZhaPKimS, et al. (2018) Health care needs and care utilization among lesbian, gay, bisexual, and transgender populations in New Jersey. Journal of Homosexuality65(2): 167–180.
52.
RubenMAFullertonM (2018) Proportion of patients who disclose their sexual orientation to healthcare providers and its relationship to patient outcomes: A meta-analysis and review. Patient Education and Counseling101: 1549–1560.
53.
RyanWSHungerJMMajorB (2017) Applying intergroup relations research to understanding LGB health disparities. Journal of Social Issues73(3): 477–492.
54.
SabinJARiskindRGNosekBA (2015) Health care providers’ implicit and explicit attitudes toward lesbian women and gay men. American Journal of Public Health105(9): 1831–1841.
55.
SchilderAJKennedyCGoldstoneIL, et al. (2001) “Being dealt with as a whole person.” Care seeking and adherence: The benefits of culturally competent care. Social Science & Medicine52(11): 1643–1659.
56.
SmithDMMathewsWC (2007) Physicians’ attitudes toward homosexuality and HIV: Survey of a California medical society-revisited (PATHH-II). Journal of Homosexuality52: 1–9.
57.
SteeleCM (1997) A threat in the air: How stereotypes shape intellectual identity and performance. American Psychologist52(6): 613–629.
58.
SteeleCMSpencerSJAronsonJ (2002) Contending with group image: The psychology of stereotype and social identity threat. In: Advances in Experimental Social Psychology, vol. 34. Waltham, MA: Academic Press, pp.379–440.
59.
SteeleLSTinmouthJMLuA (2006) Regular health care use by lesbians: A path analysis of predictive factors. Family Practice23(6): 631–636.
60.
StevensFGPlautVCSanchez-BurksJ (2008) Unlocking the benefits of diversity: All-inclusive multiculturalism and positive organizational change. The Journal of Applied Behavioral Science44(1): 116–133.
61.
SchwartzJGrimmJ (2019) Stigma communication surrounding PrEP: The experiences of a sample of men who have sex with men. Health Communication34(1): 84–90.
62.
VolpeVVDawsonDNRahalD, et al. (2019) Bringing psychological science to bear on racial health disparities: The promise of centering Black health through a critical race framework. Translational Issues in Psychological Science5(4): 302.
63.
WilkinsonS (1998) Focus groups in health research: Exploring the meanings of health and illness. Journal of Health Psychology3(3): 329–348.
64.
WilliamsSLMannAK (2017) Sexual and gender minority health disparities as a social issue: How stigma and intergroup relations can explain and reduce health disparities. Journal of Social Issues73: 450–461.
65.
WilliamsDRYuYJacksonJS, et al. (1997) Racial differences in physical and mental health: Socio-economic status, stress and discrimination. Journal of Health Psychology2(3): 335–351.
66.
WiltonLSBellANVahradyanM, et al. (2020) Show don’t tell: Diversity dishonesty harms racial/ethnic minorities at work. Personality and Social Psychology Bulletin46(8): 1171–1185.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
