Original article

Factors associated with the non-use of health services in LGBTI people from Peru

Luccio Romani ^1,2, Human Medicine Student
Katerine Ladera-Porta ³, Human Medicine Student
Dante M. Quiñones-Laveriano ⁴, Physician
Wagner Rios-Garcia ⁵, Human Medicine Student
Alejandro Juarez-Ubillus ¹, Human Medicine Student
Jennifer Vilchez-Cornejo ², Physician

¹ Facultad de Medicina Humana, Universidad de San Martín de Porres, Chiclayo, Perú.
² Red de Investigación en Salud Pública y Epidemiología, Lima, Perú.
³ Facultad de Medicina Humana, Universidad Nacional de Ucayali, Ucayali, Perú.
⁴ Universidad Continental, Lima, Perú.
⁵ Facultad de Medicina Humana, Universidad Nacional San Luis Gonzaga, Ica, Perú.

ABSTRACT

Objective: To determine the factors associated with the non-use of health services in a sample of the lesbian, gay, bisexual, transgender, and intersex population of Peru.

Materials and methods:Analytical cross-sectional study, analysis of secondary data from the First LGBTI Survey of Peru. Those who suffered from a medical condition during the last twelve months and had to receive medical attention were considered a variable of interest. Crude prevalence ratios (PRc) and adjusted (PRa), with 95% confidence intervals (95% CI) were calculated using Poisson regressions with robust variance. Three models were developed, adjusted to variables grouped according to sexual orientation, gender identity, and intersexuality.

Results: 55.4% were male at birth, the median age was 25 years (IR: 21-30). 16% stated that they had not sought medical attention. The three models presented a negative association in having suffered a chronic disease, infectious, contagious diseases, and mental illness and those who expressed their orientation openly. Not being respected for the gender they identified with was related to not using the services in model 3. Models 1 and 3 included a positive association with not being respected with the gender identified.

Conclusion: Suffering from a mental illness, an infectious contagious disease, a chronic disease, and not being treated with respect according to their gender identity are factors associated with the non-use of health services.

Keywords: Sexual and gender minorities; Health Services, Healthcare Disparities, Peru (Source: MeSH NLM)

INTRODUCTION

In recent decades, public awareness and scientific interest in addressing the problems faced by the lesbian, gay, bisexual, transgender and intersex (LGBTI) community has been increasing ⁽¹⁾. This is mainly due to heteronormativity or heterosexism, which generates violence and discrimination, and is aggravated by the stigmatization of sexual orientation ^(2,3).

The existing gaps regarding access to health services for LGBTI people are centered on the structural discrimination and institutionalized violence suffered by this community, which causes several disparities when it comes to receiving medical care. This factor is strongly associated with not seeking health services due to internalized stigma and having suffered discrimination by health workers or patients ^(3,4). This creates an environment of poor communication and mistrust in the health system from the LGBTI community; as well as chronic isolation, postponement or refusal to receive medical attention, even when their ailments can put their health at great risk ⁽⁵⁾.

A study in the United States showed that 18% of LGBTI adults reported avoidance of medical care for themselves or their family members because of anticipated discrimination, while 16% reported discrimination in health services ⁽⁴⁾. Regarding transgender individuals, one study found that they were more likely to delay seeking medical care compared with cisgender participants because they anticipate discrimination ⁽⁵⁾. Similarly, 41% of transgender women avoided seeking medical care mainly because of stigma and discrimination⁽³⁾.

In addition, some health policies, such as HIV/AIDS prevention, specifically targeted to a subpopulation (e.g., sex workers), are implemented with an unspoken labeling and stigmatization of these people, which increases the rejection of assistance provided by the health system ⁽⁶⁾. They may feel that being present or enjoying some benefit is not right for them and, therefore, may exclude themselves from healthcare services ⁽⁷⁾.

In Peru, it was reported that 26% of Peruvian members of the LGBTI community perceive that access to healthcare continues to be limited by multiple gaps regarding access. Ayacucho and Piura are the regions with the highest rate of vulnerability (39% and 35% respectively) ⁽⁸⁾. Institutionalized discrimination and violence cause inequalities when it comes to receiving medical care and constitute the institutional gaps described in various contexts ⁽⁹⁾; there is still no information on the conditions that lead an LGBTI person not to use health services in case of illness.

This research aims to determine the factors associated with the non-utilization of health services in a sample of the LGBTI population in Peru. This will help to understand the reasons why this population renounces their health rights. Likewise, the development of comprehensive care protocols and the promotion of future research focused on the LGBTI community will allow us to understand how they are treated, with the mission of establishing an initial point of discussion regarding the needed comprehensive healthcare for the most vulnerable populations, such as the LGBTI community.

MATERIALS AND METHODS

Design and area of the study

We carried out an analytical cross-sectional study, using secondary data from the First Virtual Survey for LGBTI people, conducted by the Instituto Nacional de Estadística e Informática (INEI) in 2017. This survey is of an exploratory, non-probabilistic nature, as no preliminary information was available about the size of the population.

The survey was conducted between May 17 and August 17, 2017 through an online questionnaire disseminated on the INEI website on social networks and other electronic media. We counted with the support of various LGBTI organizations to reach the target population and to try to eliminate biased responses by non-LGBTI people. The survey coverage included the entire Peruvian national territory, including urban and rural areas ⁽¹⁰⁾.

Population and sample

The survey included people 18 years of age or older, residents of Peru who identified themselves as part of the LGBTI community or who, without identifying themselves with these categories, did not ascribe to the binary or rigid definitions of masculine or feminine, and had access to the electronic questionnaire. The initial population of the survey was 12,027 participants from all over the country.

Participants were excluded if they did not answer the questions that allowed them to identify or define themselves as part of the group, corresponding to questions 112, 113, 114 and 120 of the questionnaire ⁽¹⁰⁾, which addressed sex registered at birth, sexual orientation, gender identity and intersexuality, respectively. In addition, those who did not answer questions 105 and 106, corresponding to the variable of interest that delimits those who have had a health problem during the last twelve months and have visited a health facility for care, respectively, were excluded. Finally, only members of LGBTI communities who despite having had the need to use health services did not do so for various reasons were considered. The final population was 5,386 participants.

Variables and instruments

The electronic questionnaire consisted of 71 questions, which included general data about socio-demographic characteristics such as age, sex registered at birth, education, health, occupation, identity, body and sexuality, family environment, disability, ethnicity (36 questions); discrimination and violence (11 questions); knowledge of LGBTI rights (3 questions); citizen participation (2 questions); perception of LGBTI status (4 questions) and housing and household data (5 questions).

The variables included in the study were determined based on a previous theoretical review of the barriers of sexual minorities to access health services ⁽¹¹⁾, which considered aspects related to sexual orientation, gender identity, intersexuality; in addition to socioeconomic, geographic, demand and supply aspects that influence access to health services ⁽¹²⁾. To determine the dependent variable, we first selected the persons who reported having any disease (question 105: "In the last 12 months, did you have any health problem such as..."). Then, it was cross-checked with the response "I did not seek care", an alternative response corresponding to question 106 ("Where did you go to seek care for this illness?").

We also considered questions covering the variables of age, sex registered at birth, place of residence, ethnicity, marital status, level of education, having health insurance, history of chronic noncommunicable diseases (asthma, chronic bronchitis, emphysema, arterial hypertension, diabetes mellitus) in the last 12 months, history of infectious diseases (tuberculosis, sexually transmitted infections, HIV/AIDS) or mental health (anxiety, depression), reasons for not using health services, having suffered some type of discrimination by health personnel, having been forced to undergo STI or HIV testing. In addition, we included variables regarding sexual orientation, gender diversity and sexual characteristics, sexual orientation, gender identity, intersex, whether they openly express their sexual orientation, whether a family member knows about their sexual orientation or gender identity. The definitions of the terms used in the variables corresponding to sexual diversity, gender diversity and sexual characteristics can be found in the glossary attached as supplementary material.

Procedure and statistical analysis

The data modules were downloaded from the INEI web page to analyze the data. Subsequently, the necessary data were extracted from the module uploaded in SPSS v.25, exported to a Microsoft Excel 2013 file and then we kept only the variables of interest previously delimited and corroborated by the authors.

Data were analyzed in the Stata version 15 statistical package (StataCorp, College Station, Texas, USA), where qualitative variables were presented as frequencies and percentages; quantitative variables were presented as medians and interquartile ranges, after evaluating their distribution.

Simple linear regression was applied on all variables and variance inflation factors were calculated to assess multicollinearity among the independent variables. We found that the variables gender identity, sexual orientation and intersexuality presented multicollinearity. Therefore, and due to the importance of these variables in the study, three models were developed with the intention of including these variables in the same adjusted analysis model. The multivariate analysis included in each model the variables with a p < 0.20 in the bivariate analysis: age, place of residence, educational level, health insurance, history of STIs, history of chronic noncommunicable diseases, history of mental health diseases, fearlessly expressed sexual orientation, partner relationship, forced to be tested for STIs, the gender with which he/she identifies was not respected, had to change his/her appearance, and sex registered at birth.

For each model, crude (PRc) and adjusted (PRa) prevalence ratios and their 95% confidence intervals (95% CI) were calculated using Poisson regressions with robust variance. A statistically significant association was considered when the prevalence ratios with a 95% CI did not include 1.

Ethical considerations

The protocol of this study is included in the National Registry of Health Research Projects (PRISA) of the INS (Registration code: EI0000000660). In addition, the ethical considerations expressed in the Helsinki declaration were taken into account. Only the data considered relevant for the study were extracted from the database, and those that would allow us to recognize the identity of the individuals were ignored. The data used in the present investigation are of public domain and do not contain information that would allow the identification of any individual.

RESULTS

There was a final population of 5,386 people, after excluding 6.4% (771) for not identifying themselves as part of the group (heterosexuals, non-intersexuals, non-transgender) and 48.8% (5,870) for not answering if they presented any disease in the last twelve months; finally, 0.1% (11) of the records were eliminated because they had incomplete and non-concordant information whose content was offensive and/or obscene at the time of evaluation by the authors, these data are shown in detail in a flow chart (Figure 1).

Figure 1. Flowchart of the selection of the study population.

From the final population, 55.4% (2984) were registered as male at birth, the median age was 25 years (IQR: 21 to 30); 44.2% (2,379) reported being gay, 5.9% (316) were transsexual and only 4.4% (233) reported being intersex. Likewise, 57.1% (3,058) of the participants reported having university education and 52.2% (2777) reported not having a partner. The other general characteristics are summarized in Table 1.

Table 1. General characteristics of the studied LGBTI population.

^aa Median and interquartile ranges; ^b pansexual, asexual, demisexual; ^c transsexual, transgender, transvestite; ^d persons of non-binary gender.

Regarding health, 29.7% (1,600) reported not having insurance. During the last twelve months, 49.4% (2,658) reported having suffered from some mental illness associated to adaptation disorders, such as anxiety or depression. However, 16% (862) of the participants reported that they had not sought medical care, with lack of money being the most frequent reason (31.3%). The geographic distribution of non-use of health services is shown in Figure 2.

Figure 2. Frequency of non-utilization of health services by geographic location.

Regarding the non-use of health services, the multivariate analysis showed a negative association in the three models with having graduate studies, having suffered from a chronic non-communicable disease, having suffered from a sexually transmitted infection, and openly expressing sexual orientation or gender identity; in addition, model 3 included a negative association with residing in Lima. Likewise, a positive association was found in all three models with having presented some mental health problem corresponding to an adaptive disorder; on the other hand, models 1 and 3 included a positive association with not being respected because of the gender with which he/she identifies (Table 2).

Table 2. Bivariate and multivariate analysis between factors associated with the non-utilization of health services among LGBTI people in Peru.

Model 1. Includes the sexual orientation variable. Model 2. Includes the variable gender identity. Model 3. Includes the variable intersexuality. ^a demisexual, sapiosexual.
PRa: adjusted prevalence ratio; 95% CI: 95% confidence interval

DISCUSSION

This research found that socioeconomic limitation and lack of trust in health personnel were the main reasons for not using health services, which are related to what has been reported in previous studies; where, compared to heterosexuals, sexual minorities tend to delay care due to cost, previous negative experiences in medical care, not being able to obtain appointments, and avoiding bothering a care provider ⁽¹³⁾. One in six LGBTI adults reported that they avoided seeking care due to anticipated and experienced discrimination in health care settings ⁽⁴⁾.

We found that having postgraduate education decreased the prevalence of non-utilization of health services. Although specific studies of this determinant in the LGBTI population are scarce, it is known that educational level influences adequate access to healthcare ⁽¹⁴⁾. A higher level of education is related to a better socioeconomic level and fewer barriers to access health services ⁽¹⁵⁾. On the other hand, residing in Lima decreased the frequency of non-utilization of health services. This could be due to the fact that, unlike other cities in Peru, Lima has progressively implemented health services with a rights-based approach oriented towards the integration and acceptance of the LGBTI population ⁽¹⁶⁾. The challenge remains to implement and strengthen them at the national level ⁽¹⁷⁾.

We also found that the prevalence of non-utilization of health services was lower in those who had health insurance. Not having health insurance could imply the need to make a payment for medical care, which would constitute an economic barrier. This is consistent with reports from the United States, where sexual minorities had a higher frequency of delaying medical care because of costs ⁽¹⁸⁾. Although the majority of the population reported being affiliated with health insurance, there are groups, such as the transgender population, that find it difficult to be affiliated because they often do not use their legal name because it does not coincide with their gender identity ⁽¹⁹⁾ or because the services offered do not adequately cover their needs ⁽²⁰⁾.

On the other hand, almost half of the sample population reported having suffered some mental health problem in the last twelve months. This finding is similar to that reported in various national and international studies ^(21,22), where the stress of minorities, stigmatization and discrimination negatively affect their mental health ⁽²³⁾, particularly in intolerant environments such as the Peruvian society ⁽²⁴⁾. This makes adequate care of mental health problems of LGBTI people a priority; however, unlike health problems such as chronic non-communicable diseases or STIs, mental illness increased the prevalence of non-utilization of health services. A Canadian study reports that sexual minorities’ main barriers to mental health care were inability to pay, insufficient insurance coverage, preferring to "wait" for problems to go away, discomfort talking about emotions, and embarrassment⁽²⁵⁾. Of these barriers, the last two are likely to have particular connotations in the Peruvian context, where health personnel are not trained to care for LGBTI people and, even worse, could have negative attitudes towards them ⁽²⁶⁾. This would lead not only to inadequate mental health care, but also to the exposure to negative or violent attitudes. Given the specific challenges of LGBTI people, such as problems in identity development, couple relationships, parenting problems, problems related to their families, among others, there is a need to include guidelines throughout the country to address their mental health, and to decrease heterosexism and bias in medical care^(26,27).

We observed that fearlessly expressing their sexual orientation and gender identity increased the frequency of non-utilization of health services. This patient empowerment could facilitate appropriate medical care for their health problems; however, it must be accompanied by an environment that facilitates this scenario. Thus, a study in the United States found that, in those states with laws against discrimination against sexual minorities, sexual minority women were more likely to declare their gender identity or sexual orientation to their health care provider, which improved medical care and patient satisfaction ⁽²⁸⁾.

On the other hand, we also found that, in the models for gender identity and intersexuality, not respecting the gender with which the patient identifies increased the prevalence of non-utilization of health services. This is consistent with a study conducted in the United States, where transgender individuals were found to have a high proportion of delaying or not seeking medical care due to health system discrimination ⁽²⁹⁾. It has also been observed that health care providers, especially heterosexual and male providers, may have negative attitudes towards LGBTI patients, which is a manifestation of the systemic discrimination to which our society subjects them ⁽²⁶⁾.

It has been found that recognizing oneself as intersex decreased the frequency of non-utilization of health services. This may be because intersex persons need adequate medical care to understand the physical characteristics of intersex and non-binary gender identity until the patient is able to identify with some gender and some sex, if desired ⁽³⁰⁾. Research on the problems affecting intersex people is still scarce, so these findings should be contextualized in the framework of specific studies that can lead to better policies, education, health care, and ethical responsibility on the part of our healthcare system.

It is important to provide information on the needs of LGBTI people in general and with emphasis on future health professionals, with useful and reliable information that includes comprehensive care for the LGBTI-oriented community. Likewise, the State, in its duty to ensure a universal health service respecting the rights of all people, should address the disparities in access and use of health services that are currently fragmented, being this group one of the most vulnerable. The creation of comprehensive care protocols with a focus on LGBTI people would make it possible to sensitize and educate health personnel.

This research had several limitations. The survey, being of a non-probabilistic exploratory nature, did not include prior information on the size of this population in order to select a sample. In view of this, the results obtained refer to the population that participated in the survey and cannot be extrapolated to the total LGBTI population of Peru. Because the survey was conducted virtually, access was limited to only LGBTI people who had internet access. Some of the questions correspond to events that occurred up to twelve months in advance, so there could be memory bias in the filling out of the survey, despite this, the variables included define in a detailed and specific manner each of the variables of interest. Likewise, the self-reported survey responses may constitute an information bias. Finally, the design of the survey prevented a case-control study, so there is no cause-effect directionality between the associated factors and the non-utilization of health services.

Finally, we can conclude that having a mental illness and not being treated with respect according to gender predisposed members of the LGBTI community not to use health services. In contrast, the factors that influenced them to use health services were having openly expressed their sexual orientation or being affiliated with some type of health insurance.

REFERENCES

1. Russell ST, Fish JN. Mental Health in Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth. Annu Rev Clin Psychol. 2016;12:465–487. doi: 10.1146/annurev-clinpsy-021815-093153.

2. Zeeman L, Sherriff N, Browne K, McGlynn N, Mirandola M, Gios L, et al. A review of lesbian, gay, bisexual, trans and intersex (LGBTI) health and healthcare inequalities. Eur J Public Health. 2019;29(5):974-80. doi: 10.1093/eurpub/cky226.

3. Socías ME, Marshall BD, Arístegui I, Romero M, Cahn P, Kerr T, et al. Factors associated with healthcare avoidance among transgender women in Argentina. International Journal for Equity in Health. 2014;13(1):81. doi: 10.1186/s12939-014-0081-7.

4. Casey LS, Reisner SL, Findling MG, Blendon RJ, Benson JM, Sayde JM, et al. Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019;54(S2):1454-66. doi: 10.1111/1475-6773.13229.

5. Lazo-Gonzales O, Alcalde-Rabanal J, Espinosa-Henao O. El sistema de salud en Perú: Situación y desafíos [Internet]. Lima: Colegio Médico del Perú; 2016. [citado el 19 de noviembre de 2020]. Disponible en: http://web2016.cmp.org.pe/wp-content/uploads/2016/12/libroSistemaSaludPeru.pdf.

6. The Lancet Public Health. LGBT: the vital fight for the right to health. Lancet Public Health. 2019;4(3):e116. doi: 10.1016/S24682667(19)30025-8.

7. Kavanagh M, Baral S, Milanga M, Sugarman J. Biometrics and public health surveillance in criminalised and key populations: policy, ethics, and human rights considerations. Lancet HIV. 2018; 6(1):51-59. doi: 10.1016/S2352-3018(18)30243-1.

8. Informe LGBT 2018. Derecho a la igualdad de las personas LGBT en el Perú: Perspectivas jurídicas y políticas [Internet]. Lima: Promsex; 2018 [citado el 13 de agosto de 2020]. Disponible en:https://promsex.org/publicaciones/informe-lgbt-2018-derecho-a-la-igualdad-de-las-per­sonas-lgbt-en-el-peru-perspectivas-juridicas-y-politicas/.

9. Paulino DB, Rasera EF, Teixeira FDB. Discourses on the healthcare of lesbian, gay, bisexual, and transgender (LGBT) people adopted by doctors working in Brazil’s family health strategy. Interface Commun Heal Educ. 2019;23. doi: 10.1590/interface.180279.

10. Instituto Nacional de Estadística e Informática del Perú. Primera Encuesta Virtual para Personas LGBTI 2017 [Internet]. INEI; 2017. [citado el 19 de julio de 2020]. Disponible en:http://iinei.inei.gob.pe/microdatos/index.htm.

11. Catalán Aguila M. Principales barreras de acceso a servicios de salud para personas lesbianas, gay y bisexuales. Cuad Méd Soc. 2018;58(2):43-7.

12. Sánchez-Torresa DA. Accesibilidad a los servicios de salud: debate teórico sobre determinantes e implicaciones en la política pública de salud. Rev Med Inst Mex Seguro Soc. 2017;55(1):82-9.

13. Tabaac AR, Solazzo AL, Gordon AR, Austin SB, Guss C, Charlton BM. Sexual orientation-related disparities in healthcare access in three cohorts of U.S. adults. Prevent Medicine. 2020;132:105999. doi: 10.1016/j.ypmed.2020.105999.

14. Rivera-Felix LM, Burgos-López NH, Gomez-Diaz JZ, Moquillaza-Al­cántara VH. Factores asociados al acceso a la atención prenatal en los hospitales de Huaral y Chancay, Perú. An Fac med. 2018; 79(2):131-137. doi: 10.15381/anales.v79i2.14939.

15. Mantilla-Villabona LY, Maturana-Martinez DMA, Ospina-Galeano DC, Amado-Niño AM, Uribe Perez CJ. Barreras para la atención en salud durante el diagnóstico y tratamiento del cáncer gástrico. MedU-NAB. 2017;19(3):211-220. doi: 10.29375/01237047.2262.

16. Andina. Minsa implementa enfoque de respeto de la población LGTBI en servicios de salud mental. [Internet]. [Citado el 11 de setiembre de 2020]. Disponible en: https://andina.pe/agencia/noticia-minsa-implementa-enfoque-respeto-de-poblacion-lgtbi-servicios-salud-mental-753436.aspx.

17. Martos A, Wilson P, Meyer I. Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape. PLoS One. 2017; 12(7):e0180544. doi: 10.1371/journal.pone.0180544.

18. Trinh MH, Agenor M, Austin B, Jackson CL. Health and healthcare disparities among U.S. women and men at the intersection of sexual orientation and race/ethnicity: a nationally representative cross-sectional study. BMC Public Health. 2017. 17:964. doi: 10.1186/s12889-017-4937-9.

19. Salazar X, Villayzan J, Silva-Santisteban A, Cáceres C. La Situación de las Personas Trans en el Perú: Aspectos Sociales y Epidemiológicos [Internet]. Lima: Universidad Peruana Cayetano Heredia; 2010 [citado el 18 de febrero de 2020]. Disponible en: https://www.researchgate.net/publication/245180632_La_Situacion_de_las_Personas_Trans_en_el_ Peru_Aspectos_Sociales_y_Epidemiologicos.

20. Claire Learmonth C, Viloria R, Lambert C, Goldhammer H, Keuroghlian A, Barriers to insurance coverage for transgender patients. Am J Obstet Gynecol. 2018;219(3):272. doi: 10.1016/j.ajog.2018.04.046.

21. Sattler F, Durrbaum T. Minority stress and mental health in lesbian, gay male, and bisexual youths: A meta-analysis. J LGBT Youth. 2020;17(3):2098-314. doi: 10.1080/19361653.2019.1586615.

22. Rinehart R, Rao D, Amico R, Ruiz E, Brandes E, Correa C, et al. Experienced HIV-Related Stigma and Psychological Distress in Peruvian Sexual and Gender Minorities: A Longitudinal Study to Explore Mediating Roles of Internalized HIV-Related Stigma and Coping Styles. AIDS Behav. 2019;23,661–674. doi: 10.1007/s10461-018-2348-2.

23. Verrelli S, White FA, Harvey LJ, Pulciani MR. Minority stress, social support, and the mental health of lesbian, gay, and bisexual Australians du­ring the Australian Marriage Law Postal Survey. Aust Psychol. 2019;1–11. doi: 10.1111/ap.12380.

24. Juárez-Chávez E, Cooney E, Hidalgo A, Sánchez J, Poteat T. Violence Experiences in Childhood and Adolescence Among Gay Men and Transgender Women Living in Perú: A Qualitative Exploration. J Interpers Violence. 2018;886260518787811. doi: 10.1177/0886260518787811.

25. Ferlatte O, Salway T, Rice S, Oliffe JL, Rich AJ, Knight R, et al. Perceived Barriers to Mental Health Services Among Canadian Sexual and Gender Minorities with Depression and at Risk of Suicide. Community Ment Health J. 2019;55(8):1313–21. doi: 10.1007/s10597-019-00445-1.

26. Huarcaya-Victoria J, Dávila-Palacios J, de la Cruz-Oré J. Relationship between the attitude towards homosexuality and religious attitude in physicians of a general hospital. An Fac med. 2018;79(2):138-143. doi: 10.15381/anales.v79i2.14940.

27. Pachankis JE, Goldfried MR. Clinical issues in working with lesbian, gay, and bisexual clients. Psychother Theory Res Pract. 2004;41:227–46 doi: 10.1037/2329-0382.1.S.45.

28. Baldwin A, Dodge B, Schick B, Sanders S, Fortenberry D. Sexual Minority Women’s Satisfaction with Health Care Providers and State-level Structural Support: Investigating the Impact of Lesbian, Gay, Bisexual, and Transgender Nondiscrimination Legislation. Women’s health issues. 2017;27(3):271-8. doi: 10.1016/j.whi.2017.01.004.

29. Jaffee K, Shires D, Stroumsa D. Discrimination and Delayed Health Care Among Transgender Women and Men. Medical Care. 2016;54(11):1010-16. doi: 10.1097/MLR.0000000000000583.

30. Zeeman L, Aranda KA. Systematic Review of the Health and Healthcare Inequalities for People with Intersex Variance. Int J Environ Res Public Health. 2020;17(18):6533. doi: 10.3390/ijerph17186533.

Funding: Self-funded.

Supplementary material: Available in the electronic version of the RPMESP.

Cite as: Romani L, Ladera-Porta K, Quiñones-Laveriano DM, Rios-Garcia W, Juarez-Ubillus A, Vilchez-Cornejo J. [Factors associated with the non-use of health services in LGBTI people from Peru]. Rev Peru Med Exp Salud Publica. 2021;38(2):240-7. doi: https://doi.org/10.17843/rpmesp.2021.382.6149.

Correspondence: Luccio A. Romaní Ojeda; Avenida Víctor Raúl Haya de la Torre 565, Chiclayo, Lambayeque, Peru; luccioromani@gmail.com

Author contributions:LR and JVC conceived, designed the study, and analyzed the data collected. LR, KLP, WRG, and AJU collected the data. DQL analyzed the data and was responsible for critical revision of the manuscript. All authors participated in drafting, revising, and approving the manuscript for publication, and declare themselves responsible for its content.

Conflicts of interest: The authors declare that they have no conflicts of interest.

Received: 08/07/2020

Approved: 03/02/2021

Online: 22/06/2021