Background

In recent years, research on lesbian, gay, bisexual, trans*, queer/questioning (LGBTQ+) youth has shifted from risk-based to resilience research. Research suggests that three factors contribute to resilience: environmental support (e.g. school, family), positive interpersonal relationships (e.g. LGBTQ+ peers), and intrapersonal aspects (e.g. self­ efficacy, ability to define one's own gender). Unfortunately, even in settings that could contribute to building LGBTQ+ youths' resilience, this population often encounters rejection, bullying, and even violence in the everyday spaces they inhabit. As a result, adolescent sexual and gender minorities (SGM) are at heightened risk for adverse mental and physical health events, compared with their heterosexual, cis-gendered peers. Yet little information exists on the experiences of older (15-19 years) LGBTQ+ teens in the New Zealand healthcare system. International research indicates that LGBTQ+ people encounter barriers to healthcare access that arise from stigma and discrimination. A recent New Zealand study (Veale et al., 2019) of trans* teens and adults showed they, too, encounter difficulties accessing and receiving gender-affirming care.

This study aimed to examine whether a sample of LGBTQ+ teens in New Zealand perceive interpersonal barriers to health care services. In addition, the study aimed to explore whether perceptions of health care barriers influence sexual risk behaviours, and uptake of preventive behaviours. This specific relationship has not been examined in earlier studies either.

Methods

Adopting a mixed methods, sequential explanatory study design, this research comprised an online anonymous survey with 310 respondents and in-depth, semi-structured qualitative interviews with a convenience sample of 15 LGBTQ+ teens. The survey included multiple choice and open-ended questions. Descriptive statistics and regression analysis were used to analyse the multiple choice questions. Content analysis was done on the open­ ended questions. The qualitative interviews were analysed using reflexive thematic analysis (Braun & Clarke, 2006).

Results

By combining quantitative and qualitative data, I was able to generate a more complete picture of the answers to my research questions. Building on the quantitative survey data to develop interview questions, which in turn expanded on and illustrated the quantitative findings.

This study found that participating LGBTQ+ teens perceive interpersonal barriers to healthcare services, and these barriers have potentially serious consequences not only in the sexual health arena but also in terms of the participants' emotional wellbeing. The impact of these barriers seemed most pronounced in the gender diverse population.

The participants predominantly attributed these barriers to lack of knowledge and training on the providers' side. Such perceptions caused participants to feel dismissed or misunderstood, and at times reluctant to continue seeking care. The perception of barriers also stems from the participants' own experiences of being LGBTQ+, driving their fear of coming out to providers lest they suffer discrimination and judgement, which may be a common occurrence in other areas of their lives.

Participants' experience of a widespread heteronormative attitude in healthcare allows them to continue receiving care without having to come out. However, this attitude adds a layer of complexity and additional barriers to gender diverse individuals who require, at minimum, gender-affirming care in the form of respectful language.

These above barriers, and the perceived lack of adequate sexuality education resources elsewhere, create a knowledge gap in the study population. No direct connection was found between sexual risk behaviour and participants' ability to fully utilise healthcare services as LGBTQ+ individuals. However, the barriers found in this study contributed to lack of knowledge and lower uptake of preventive measures, which increase the risk of adverse outcomes (e.g. STI exposure) in this study population.

Conclusions

In a population already affected by marginalisation, participants' healthcare needs are not being met. This was especially true with regards to gender minority participants. Gender diversity was also associated with a lower health communication self-efficacy score, itself a barrier to healthcare utilisation.

Mental health struggles were commonly reported in the interviews, and participants related those to being LGBTQ+ (the most cited factor) and New Zealand's inadequate mental health system. Long wait times for mental health appointments, as well as being told that "asking for help means you're well enough" raise the risk of exacerbating depression, anxiety, and suicidal ideation. These are conditions that already affect LGBTQ+ adolescents disproportionally.

Participants' common concerns (e.g. confidentiality, denial of care, judgement and discrimination) around disclosing their sexual or gender identity, together with other research, indicate there are serious gaps in meeting the healthcare, including sexual health needs, of LGBTQ+ teens in New Zealand. These common concerns make the necessity of repeatedly coming out to new providers a daunting task for these participants. Inability to discuss their SGM status openly also creates a knowledge gap in sexual health knowledge, resulting in possible public health implications.