Date of Award

January 2026

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jeffrey M. Cohen

Abstract

Background: There is limited research on the prevalence of barriers to care among sexual and gender minority (SGM) patients with chronic inflammatory skin diseases (CISDs) in the US.Research Aims: Our aim in this study was to compare the prevalence of cost and noncost barriers to care among SGM and non-SGM patients with CISDs and to analyze the prevalence of barriers based on intersecting identities of sexual orientation, gender identity, and race and ethnicity. Questions: How does the prevalence of barriers to care compare between SGM patients and non-SGM patients with CISDs? How do intersecting identities of sexual orientation, gender, and race and ethnicity affect the odds of experiencing barriers? Methods: We conducted a cross-sectional study of health care access and utilization survey data from the National Institutes of Health’s All of Us Research Program. Participants were adults ages 18 years or older with CISDs who enrolled in All of Us directly online or through partner health care practitioner organizations located across the US between May 31, 2017, and July 1, 2022. The primary outcome was the odds of experiencing cost and noncost barriers to health care among SGM patients with CISDs compared to non-SGM patients with CISDs. Multivariable logistic regression models – adjusting for age, race and ethnicity, region, as well as the socioeconomic status factors of income, insurance, and education level (fully adjusted model) – were used to examine the association of SGM status with experiencing the barriers to care. In our secondary analysis, we further analyzed the odds of experiencing barriers based on intersecting identities of sexual orientation, gender, and race and ethnicity (i.e., for instance, comparing the prevalence of barriers among non-Hispanic Black women identifying as SGM to non-Hispanic White women identifying as non-SGM). Results: This study included 19,743 patients with CISDs, including 1,877 SGM patients (median age, 40.5 years [IQR, 28.7-57.9 years]; 1,205 [64.2%] assigned female sex at birth) and 17,866 non-SGM patients (median age, 57.1 years [IQR, 40.8-68.1 years]; 13,205 [73.9%] assigned female sex at birth). Among the most common CISDs in the cohort were acne (prevalence among SGM patients, 50.8%; prevalence among non-SGM patients, 40.8%), rosacea (SGM, 20.8%; non-SGM, 28.6%), psoriasis (SGM, 19.9%; non-SGM, 21.2%), and atopic dermatitis (SGM, 17.1%; non-SGM, 16.9%). Compared with non-SGM patients, SGM patients with CISDs were significantly more likely to delay specialist care (adjusted odds ratio [aOR], 1.23; 95% confidence interval [95% CI], 1.03-1.47), mental health care (aOR, 1.62; 95% CI, 1.37-1.91), and filling a prescription (aOR, 1.30; 95% CI, 1.11-1.52) because of cost. In addition, SGM patients with CISDs were significantly more likely than non-SGM patients to delay care because of transportation issues (aOR, 1.49; 95% CI, 1.22-1.80) and not having a health care practitioner who shares the same background with regard to race and ethnicity, religion, native language, sexual orientation, and gender identity (aOR, 1.39; 95% CI, 1.19-1.62). SGM patients with CISDs were also significantly more likely than non-SGM patients to report not always being treated with respect by their health care practitioners (aOR, 1.47; 95% CI, 1.30-1.65). When further stratifying participants by SGM status, gender identity, as well as race and ethnicity, the odds ratio effect sizes for experiencing barriers were numerically largest among non-Hispanic Black and Hispanic/Latino women and men identifying as SGM. Scientific Impact: The findings of this cross-sectional study suggest that SGM patients with CISDs – particularly those SGM patients also identifying as non-Hispanic Black or as Hispanic/Latino – may be disproportionately affected by cost and noncost barriers to health care. Dermatologists and other health care practitioners caring for SGM patients with CISDs have an important role in helping to address these barriers and larger systemic issues for SGM patients at both the patient and system levels.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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