Dissertations and Theses

Date of Degree

6-1-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (Ph.D.)

Department

Community Health and Social Sciences

Advisor(s)

Christian Grov

Committee Members

Emma Tsui

Naomi Zewde

Subject Categories

Community Health and Preventive Medicine | Health Services Research | Other Social and Behavioral Sciences | Public Health

Keywords

LGBTQ+, HIV prevention, Mental health care, Gender affirming care, Health Equity, Health insurance

Abstract

In the U.S. there continue to be stark disparities in health that affect LGBTQ+ communities. These disparities include those related to mental health, sexually transmitted infections, along with chronic illnesses and some cancers. Higher health needs across diagnostic categories mean that LGBTQ+ individuals require access to the healthcare system both to prevent conditions disproportionately affecting the community, and to treat conditions as they arise. In the U.S., access to healthcare often requires either reliable insurance coverage or another payer to cover costs associated with care. Thus, health insurance status and coverage of care, along with coverage regulations and health policies that influence healthcare access, play a critical role in facilitating, barring and complicating access to care. Moreover, insurer practices may extend beyond covering or not covering care, to include practices that “manage” access to care through utilization management practices, provider network limitations, medication tiering and other practices that seek to contain the costs associated with care. Although there have been efforts to track the health insurance status of LGBTQ+ populations within the extant literature, rarely has this body of work interrogated how insurer-led practices impact health equity. This dissertation seeks to fill this gap in the literature by assessing how insurer-driven and payment barriers affect healthcare navigation for cisgender gay and bisexual men and transmasculine populations through the following three study aims:

First, I analyzed in-depth interviews with transmasculine individuals from across the U.S. about their gender-affirming care experiences with a focus on insurance, payment and policy-related barriers to care. Interviews were conducted via video-conferencing software, analyzed using a codebook approach to thematic analysis, and contextualized within a broader analysis of the policy landscape dictating coverage for gender-affirming care. Participants reported insurance denials for gender-affirming care, as well as challenges with prior-authorization requirements, letter requirements, restrictive formulary lists and other challenges that complicated and/or barred access to care. Many discussed adaptive strategies to these challenges, which included utilizing community resources and knowledge, as well as receiving material support from family, friends, and partners, and developing technical and interpersonal savvy skills in response to insurance challenges. These findings illuminate the persisting challenges that transmasculine individuals face when attempting to access and pay for gender-affirming care.

Second, I conducted a quantitative assessment of the prevalence of insurance denials and cost-sharing associated with pre-exposure prophylaxis (PrEP) among sexual and gender minority individuals (SGM) in the U.S. Between August 2022–July 2023, we recruited SGM individuals via geosocial networking applications. Individuals completed a screening survey for a cohort study focused on HIV prevention, which also assessed insurance denials and cost-sharing associated with PrEP. Of 11,410 individuals reporting current or former PrEP use, 23.7% had experienced a denial for their PrEP (ever), which ranged from 8.5% for generic TDF/FTC to 48.2% for Descovy. Additionally, 34.6% reported experiencing cost-sharing within the past two years. The majority (58.3%) of instances of reported cost-sharing were for laboratory bloodwork, and most (61.5%) were privately insured. Continued insurance denials and cost-sharing associated with PrEP necessitate further policy intervention.

Third, I conducted and analyzed interviews exploring gay and bisexual men’s mental healthcare navigation, with a specific focus on identifying challenges that arose when seeking mental health care. Between July and September of 2023, 24 individuals participated in in-depth interviews via video-conferencing software. Interviews were transcribed and analyzed using a reflexive thematic approach. Participants reported challenges navigating insurance networks to access care, which often engendered frustration and emotional upset. Participants desired mental health providers that could provide affirming and culturally-tailored care, with a preference for providers from the LGBTQ+ community and with racial and ethnic backgrounds that were concordant with their own. Such needs were complicated by narrow provider networks, limited resources and provider directories replete with inaccuracies and unavailable providers. Participants also highlighted cost-related challenges, including high out-of-pocket costs associated with care and treatment limitations that restricted access to care over time. Our findings support that gay and bisexual men experience challenges when seeking mental health care that also affect the broader population, but may be magnified for this population, particularly for men of color seeking care from a smaller sub-set of providers prepared to be deliver culturally-tailored and affirming and care to LGBTQ+ individuals.

Reliable access to care is paramount to addressing health equity goals for LGBTQ+ individuals. As outlined, insurance practices that bar access to care, delay care or create financial hardship are a threat to health equity, including for LGBTQ+ communities and marginalized racial and ethnic groups across the U.S. Addressing these practices will require strengthened enforcement mechanisms that ensure that insurers follow existing laws that protect consumers from predatory practices, as well as more expansive policy solutions that move us away from profit-driven insurer practices. Such changes will rely on accurate data to describe and analyze insurer practices, and evidence-based solutions that can guide policymakers, healthcare and public health experts working to pass and implement new systems of payment for care in the U.S. at the state and/or federal levels.

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