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LGBT community organizations provided health services to at least , clients in [ 8 ], suggesting that they still constitute a significant proportion of the healthcare landscape for LGBT people today. These studies focus predominantly on the general population healthcare landscape and offer limited consideration for LGBT health services.

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We begin with a review of early intersections of sexuality and health and the evolution of LGBT health services over time. Informed by this, we present an asset map displaying the location and types of services provided by LGBT community health centers today in relation to the population density of LGBT people. Given the diversity of the LGBT community, it is prudent to describe how identity labels are utilized in describing the findings below.

For example, although not everyone outside of heterosexual, cisgender i. Other terms will be incorporated to describe particular political, medical, or social moments or perspectives, rather than LGBT people themselves. There is no clear beginning to the relationships between sexuality, social and political movements, and health. But the interplay of these factors in the formation of LGBT identities in the United States has origins in the mid th Century [ 16 ].

Prior to adopting more consolidated identities of lesbian, gay, bisexual, and transgender, unorganized and isolated individuals first sought to identify and connect with each other in the politically and socially hostile climate following World War II [ 20 ].

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The Mattachine Society [ 20 ] and the Daughters of Bilitis [ 21 ]. These moves toward self-acceptance and identity development would ultimately encourage public advocacy for the rights and social acceptance of a broader community. Concurrent with this early mobilization were several other pivotal developments that helped the increasingly organized groups of LGBT people challenge the illness model of homosexuality.

Early forms of activism among LGBT people leveraged these studies in order to dismantle the definition of homosexuality as a psychological disorder. In , the first transgender-specific magazine in the United States, Transvestia , was published [ 26 ]. It also argued against the criminalization of gender non-conforming dress and promoted early ideas of transgender people as a minority community [ 26 ].

Transgender people continued to organize throughout the s, developing community and activist organizations and promoting research into medical gender confirmation procedures [ 26 , 27 ]. These efforts were vital in pushing back against anti-homosexual political action that prevailed following s McCarthyism. The rise of consumerism, a growing working class of women, and feminist and civil rights critiques following World War II resulted in many sexual and gender norms being dissolved or reconfigured. LGBT people were sought out, arrested, and exposed under the guise of protecting the social order.

In such a hostile climate, new forms of political and social organizing and advocacy were needed [ 28 ]. The Stonewall riots of represent a significant turning point for LGBT people, who not only protested against the frequent police raids in New York City but also organized a nationwide, grassroots liberation movement [ 16 ].

Though not by any means the first form of public protest from LGBT people [ 29 ], it served as a very visible and forceful catalyst to national organizing as sexual minorities began identifying services they could not adequately receive elsewhere and providing for themselves [ 5 , 16 ]. Transgender people were then systematically excluded from LGB groups, who wanted to distance themselves from notions of deviance and medical pathology that transgender people now carried the burden of [ 32 ].

Likewise, feminist groups resisted the inclusion of transgender people, leaving them with few social and political allies throughout the s and s [ 26 ]. Medical, legal, and psychotherapeutic professionals working with transgender people continued to provide healthcare, conduct research, and develop standards of care via professional organizations like the World Professional Association for Transgender Health WPATH; formerly the Harry Benjamin International Gender Dysphoria Association, founded in [ 26 , 33 ].

Such organizations were among the few resources that remained to transgender people through the s. With homosexuality no longer included in the DSM, large numbers of LGB people were able to create visible communities in urban hubs [ 4 ]. Though these communities by no means flourished in all areas, the rapid growth of LGB organizations throughout the country enabled the once disparate people to share information across communities and better serve their local needs. It was soon recognized that many LGB people were stigmatized when accessing services in general healthcare settings, and as a result many LGB organizations took it upon themselves to offer an alternative source of care [ 3 , 6 , 34 ].

The infrastructure for community-based health services was being established with the proliferation of LGB community centers throughout the country. LGB community centers and activists began to consider the possibility of unique health issues and disparities in need of specialized attention. These programmatic shifts are visible within both emerging and pre-established community centers of the s.

Fenway Community Health, founded in in Boston, Massachusetts, was not initially established as an LGB community health center, but became the first community health center to develop expertise in LGB health services in response to the demographic needs of its own staff and clients [ 37 ]. By the mids, the National Gay Task Force listed over clinics and medical service programs and over counseling and mental health programs, with services ranging from testing and treatment for sexually transmitted infection to counseling and care for substance users, that were openly LGBT friendly and accepting [ 5 ].

Meetings held by these groups disseminated the latest HIV research and prevention strategies, developed often radical and militant strategies for social and political advocacy, and identified and organized social and healthcare services for men with HIV and AIDS who were unable to receive adequate services elsewhere [ 2 , 3 ]. LGB organizations rapidly responded by offering emotional and practical support to those affected by HIV, counseling, sex education, home-based hospice care, housing and other social services [ 1 , 2 ].

The action taken at the community level resulted in increased public awareness of HIV and AIDS and initiated action at the federal level. However, the narrow focus on HIV over the course of the s and s re-associated homosexuality with illness after long-fought struggles to disassociate from the medical field [ 41 , 42 ]. Though large amounts of federal funding were made available to research HIV among gay men, little attention was given to other health issues among either gay men or LGBs in general [ 3 ].

At the same time, transgender people re-emerged to advocate for their own uniquely transgender health issues, including issues related to HIV and gender confirmation [ 43 , 44 ]. Little has been written on the political, social, and historical milestones for transgender people during the s. On the other hand, the s saw a burst of activity that sparked an increase in activism.

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Ongoing debates within feminist studies and theory resulted in the development of a queer theory that legitimized transgender identities. Once again advocating for issues as a collective, LGBT people together produced a large body of research pointing to diverse and complex health disparities [ 45 — 49 ]. Formerly LGB organizations began re-branding themselves as inclusive of transgender individuals, and a focus on LGBT health took shape at both community and national levels [ 3 ]. The collective efforts of LGBT community centers, activists, and professionals culminated in a variety of events that aided LGBT people in gaining national recognition as an underserved population in health.

These include: In it, they synthesized decades of research on LGBT health in order to summarize what was known about the disproportionate burden of disease among LGBT people and areas for future research. Anxiety; access and other barriers to quality care; depression; suicide and suicidal ideation; eating disorders; adolescent pregnancy; obesity; HIV and other sexually transmitted infections; breast cancer; anal cancer; cervical cancer; bullying and harassment; erectile dysfunction; substance abuse including cigarettes, alcohol, and other drugs ; cardiovascular disease; and elevated rates of other cancers possibly associated with hormone treatments for transgender individuals [ 57 ].

Each of these can be recognized as relevant health concerns for LGBT populations, but researchers and community members have questioned how disproportionate health burdens could or should translate to concrete health service [ 5 , 57 ]. Guided by this review of the literature, we now turn to assess the scope of LGBT health services in the United States today. We then discuss how the LGBT health movement has shaped the contemporary landscape of LGBT health services, current gaps in service, and consider how social and political changes may influence the LGBT health service landscape moving forward.

To generate an asset map of the contemporary landscape of LGBT health services, several key constructs required operationalization. These definitions and criteria ensured that all organizations and service sites identified during data collection were appropriately categorized and, if necessary, excluded from analyses. Definitions and criteria are included in Table 1. FQHCs are also included in Table 1 in order to contrast our own definition of and criteria for LGBT community health centers with the stringent criteria that must be met in order to be recognized federally as a community health center.

Although FQHCs are able to provide much more comprehensive care than the LGBT community health centers we define here, many LGBT community health centers operate in smaller capacities and provide a variety of health services to their local community members. Initial records for LGBT organizations and their respective service sites were created using the lists of CenterLink member organizations and respondents to their biannual LGBT community center survey [ 7 , 61 ].

These lists were not mutually exclusive, and not all respondents to the biannual survey were CenterLink members, resulting in an initial list of organizations and service sites. We then searched public records for each organization using GuideStar, a database of IRS-registered non-profit organizations, to confirm non-profit status.

Any new organizations that was identified via the GuideStar search were added to the list. In the event that any of the criteria for LGBT community health centers was unavailable on an organizational website, organizations were contacted by telephone to confirm the missing data. Organizations that did not meet the criteria for LGBT community centers, or for which the criteria could not be confirmed via online search or telephone call, were excluded.

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Data collection occurred between September—December, Ten new organizations were included that had not been otherwise identified, of which two met the criteria for an LGBT community center. Neither met the criteria for an LGBT community health center. Additional categories were created for organizations whose health services did not fit within the above categories. LGBT community centers that operated a physical health clinic were also identified, and were defined as clinical spaces operated by trained and licensed healthcare personnel.

These include but are not limited to primary care clinics in that health clinics may specialize in specific services e.

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Community health centers that offer health services in the absence of a trained and licensed professional e. In all, records were created during the search for LGBT community health centers. Of these records, Of those, Same-sex households, identified using census data, is used in this study as a proxy for local LGBT population density. Doing so associated United States counties within the electronic map shapefile with their relative number of same-sex households.

The county shapefile was then overlaid above a United States shapefile displaying the state and national boundaries of the United States. Next, county areas were filled by graduated colors representing the relative proportion of same-sex households to all households per county. Finally, LGBT community health centers were geocoded, or linked to a specific geographic location within the United States map, in order to display their location relative to the local same-sex population density.

A mile buffer was created around each LGBT community health center to represent the geographic coverage area for each center. The 60 miles radius was chosen to approximate a one-hour drive from each center. Centroid locations, or the most central point of each county polygon, were calculated using ArcGIS in order to determine approximate distances between each county center and its nearest LGBT community health center. Linear regression was run to determine whether the local LGBT population density was significantly associated with the distance to the nearest LGBT community health center.

Clusters of LGBT community health centers are located on both coasts of the continental United States, with fewer or no health centers located in the center, Alaska, or Hawaii. Fig 4 displays community health centers offering transgender services, specifically, which further reduced the number of centers to only 21, which are available in only 9 states California, Connecticut, Florida, Georgia, Pennsylvania, Illinois, Massachusetts, New York, Texas and the District of Columbia. Both general health clinics and health clinics that specialize in transgender health are concentrated in the northeastern United States.

Fig 5 displays the type of services provided across all LGBT community health centers. Early efforts to protect LGBT people against societal stigma and prejudice motivated LGBT communities to provide themselves with better health services than they could not obtain in general population settings.

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In their earliest form these health services consisted predominantly of general medical, mental health, and sexual health services at LGBT organizations operating small health clinics [ 5 , 37 , 38 ]. These organizations soon included such specialized services as hospice, grief counseling, cancer prevention, peer support groups, and step programs in the era of HIV, the stigma from which left many without access to care in the general population healthcare settings [ 1 , 2 ].

LGBT health services have continued to evolve and expand in accordance with social change and medical advances.


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For example, hospice care services have presumably diminished within LGBT community health centers as HIV-related morbidity and mortality decreased, while counseling services remain common and have expanded in the types of counseling services available. The expansion of services over time demonstrates that, whether offering highly technical and specialized medical care or preventative and wellness services, a majority of LGBT community organizations have made health a priority.

The high prevalence of wellness services suggests that even organizations with limited resources may be able to engage with health promotion and prevention efforts in their communities. This study highlights a number of challenges with regard to accessing LGBT health services. First, as Fig 2 demonstrates, while significant proportions of LGBT people living on either coast live within miles of an LGBT community health center, the central states are largely under-served.

Thirteen states are devoid of LGBT community health centers altogether. And while we used a mile radius as an indicator of proximity, even a mile radius may not represent accessibility in the dense urban and coastal hubs. Moreover, proximity to any one LGBT community health center does not necessarily mean access to comprehensive LGBT health services given that each LGBT community health center provides a different combination of health services.

At the same time, we should not assume that a lack of LGBT community health centers equates to a lack of culturally competent health services. The purpose of this study is not to definitively determine all the places LGBT people can and do access culturally competent care. With that said, our own findings suggest that CenterLink and MAP have likely greatly under-reported the number of LGBT people served in , as their estimate of , people served is based upon data reported by only 62 organizations [ 8 ].

LGBT community health centers continue to be a valuable resource to LGBT people, and how these resources are invested in going forward is a matter of great concern.