Insights from the Austrian LGBTIQ+ health report 2022

Despite the growing recognition of sexual and gender minorities (SGMs) in society, certain marginalized communities still face significant barriers to accessing quality healthcare services. In the LGBTIQ+ Health Report 2022 (Gaiswinkler et al., 2023), we examined healthcare provision for lesbian, gay, bisexual, transgender, intersex, and queer (LGBTIQ+)1 individuals in Austria, aiming to uncover insights and address disparities within the healthcare landscape. This article summarizes key findings from the report, shedding light on the health and healthcare needs of SGMs. While our focus extends beyond sexual health, it is important to recognize that sexual health itself encompasses more than just physical functions and activities. Emotions, relationships and sexual identity are also crucial aspects. Gender identity and sex characteristics, like sexual orientation, are integral parts of an individual's sexual identity and thus of their overall well-being (Öffentliches Gesundheitsportal Österreich, 2021).

Recent literature underlines the stigmatization and discrimination frequently experienced by SGMs with respect to healthcare services, resulting in dis- parities in access, quality, and the availability of such services (Medina-Martínez et al., 2021; Zeeman et al., 2019). Discrimination mainly stems from heteronormative concepts and can manifest itself as stress, internalized stigmatization or victimization, which can have detrimental effects on SGMs' health (Zeeman et al., 2019).

The LGBTIQ+ Health Report 2022 covers the health status and discriminatory experiences of SGMs as well as health care and health-promoting factors (Gaiswinkler et al., 2023). Framed from a public health perspective, the report combines socioeconomic health determinants with a literature review and, most crucially, the results of a survey carried out with SGMs. An expert group supported the entire process.

To collect first-time information on the health situation of SGMs in Austria we used a mixed-methods design incorporating both quantitative and qualitative approaches. After reviewing the literature, the survey questionnaire was developed in collaboration with an external research institute (Foresight; formerly SORA) and supported by an expert group. To facilitate the comparability of the results, some of the questions in the LGBTIQ+ survey were aligned with the Austrian Health Interview Survey (ATHIS). The data (n =1,047 SGM respondents) were collected between June and September 2022. As the SGM population in Austria is not known, this sample may not be representative. Table 1 lists the respondents' characteristics. 

In September and October 2022 qualitative interviews were conducted via Zoom with 10 participants to explore hindering and facilitating factors for SGMs within the Austrian healthcare system.

Participants could provide multiple responses for their gender identity. For simplification, we condensed these responses into four groups: "trans" for those identifying as a trans woman, trans man, transgender, or expressing a trans identity in the free-text field; "inter*" for those identifying as inter-sex woman, intersex man, or inter*/intersex; "non-binary" for those identifying as non-binary, genderqueer, or using the free-text option without selecting intersex or transspecific categories; and "cis" for individuals identifying exclusively as binary female or male.

For sexual orientation, participants could not provide multiple responses, but 2 % used the open-text field for more detailed descriptions. It is important to note that self-identifications hold personal significance and individual definitions may vary. 

Self-perceived health status

When asked about their self-perceived health status, specifically, "How would you describe your overall health?", 60% of the participants responded with good/very good, while slightly less than a third rated it as average, and 11 % rated it as poor/very poor (see Figure 1). Trans and non-binary individuals tended to rate their health status lower than the average. When analyzed by sexual orientation, individuals who identify as bi-/pansexual or queer/other SO were particularly affected by poor health: 13 % of bi-/pansexual individuals and 17 % of queer individuals rated their health as poor/very poor.

Figure 2 compares our results with data from the Austrian Health Interview Survey. Not as many participants in the LGBTIQ+ survey rated their health positively (60 % good/very good) as the Austrian population as a whole (74 % good/very good). This indicates a potential disparity in self-perceived health status among SGM individuals compared to the general population.

As shown in Figure 3, 53 % of the participants had experienced depression, a prevalent mental health issue within the community. This figure reaches three-quarters among those aged 15 to 19 (30 % with a diagnosis). Over one-third of all participants disclosed struggling with anxiety disorders, with 20 % having a diagnosis. Thirty-four percent reported experiencing burnout, a phenomenon that dramatically affects general well-being although it is not classified as a distinct ICD-10 disease. One in five of the respondents revealed that they had suffered from post-traumatic stress disorder. Nearly 20 % of all respondents reported that they had experienced having eating disorders. This applied to 39 % of those aged 15 to 19, with 9 % having a diagnosis. Twelve percent of all respondents suffered from an obsessive-compulsive disorder, and 15 % disclosed other mental health conditions or chronic health problems, including autism spectrum disorder and attention deficit hyperactivity disorder. These figures underscore the burden of psychological distress among SGMs. 

The link between minority stress experienced by SGMs and its adverse effects on mental health is well documented in the literature (Pellicane & Ciesla, 2022; Silveri et al., 2022). Minority stress encapsulates the strains and adversities resulting from stigma and discrimination, significantly impacting the mental health of SGMs. Elevated risks of depression and suicide associated with such stressors are particularly highlighted in the minority stress model (Pellicane & Ciesla, 2022).

Four items relating to suicidal behaviour were included. Two-thirds of participants admitted to having contemplated taking their own lives, with 40 % confessing to having formulated plans for suicide and 14% to having attempted suicide. Forty-four percent disclosed engaging in self-harming behaviours. Reliable comparative data for suicide attempts in Austria are missing. While the official suicide rate stands at approximately 0.014 %, undocumented cases are significantly higher (BMSGPK, 2022).

Experiences of discrimination have multifaceted repercussions for affected individuals. Those who encounter discrimination are subjected to varying degrees of acute and chronic social stressors within a social hierarchy which can detrimentally affect their health (Allen, 2019). In addition, discrimination can lead to a deterioration in health status as access to resources in various life domains is significantly restricted due to discriminatory practices (Allen, 2019). 

We surveyed experiences of discrimination by asking the question: "When you think about the past two years, have you felt discriminated against in the following areas, regardless of whether it was due to your sexual orientation, gender identity, sex characteristics, or other characteristics?" Respondents reported experiencing discrimination in the areas of housing (19 %), employment or when looking for a job (32 %), education (29 %), access to services (22 %), contact with public authorities (22 %), and online platforms or social media (54 %).2 Figure 4 shows the responses with respect to the healthcare system. More than half (54 %) of the respondents reported feeling discriminated against at least occasionally in the healthcare sector in the past two years, with 12% indicating frequent experiences of discrimination during this period.

As Figure 4 illustrates, in the healthcare sector distinct groups are affected by discrimination to varying degrees. We observed similar patterns in other areas of life (see Gaiswinkler et al. (2023)). The data underscore that non-cis individuals experience high rates of discrimination. When analyzed by sexual orientation, this trend is notable among participants who do not identify as lesbian or gay.

We also inquired about the frequency of certain situ-ations occurring when accessing healthcare services (see Figure 5). 

One-third of respondents reported being denied treatment or rejected when accessing health care, 41 % stated they had been pressured to undergo specific medical or psychological procedures against their will, 29 % recounted experiences of humiliation and/or degradation, and 60 % endured inappropriate comments from healthcare professionals.

About one-third disclosed instances in which diagnoses or treatments were unjustifiably linked to their gender identity, sexual orientation, or variations in sex characteristics (SC). These issues were also highlighted in individual interviews. For instance, one participant shared a humiliating encounter with a psychiatrist who was supposed to provide an assessment for their transition. The power imbalance and lack of alternatives in the region made the experience particularly distressing. Others described the burden of having to emotionally prepare for every medical appointment to be able to deal with potential inappropriate remarks. 

Given the prevalence of discriminatory experiences described, it is important to consider their potential impact on participants' subsequent healthcare-seeking behaviours, particularly in terms of avoidance. Twenty-nine percent admitted to avoiding specialist physicians despite having health issues. One in four had avoided their general practitioner, while one in five had avoided psychosocial support services. 

Finally, we would like to touch briefly on satisfaction with the healthcare system in Austria. Slightly more than half of all respondents were somewhat or very satisfied with the healthcare system while 16% were somewhat or very dissatisfied. 

We would like to underscore recommendations for healthcare providers stemming from insights gathered in the interviews. Many of the respondents expressed a desire for inclusive forms allowing them to specify their preferred salutation, be it Mr, Ms, gender-neutral, or their chosen name. Interviewees also emphasized that queer symbolism, when used discreetly, such as a Pride flag, could communicate a welcoming atmosphere for SGMs and have a profound impact on their well-being when accessing healthcare services. Several participants stressed the importance of healthcare professionals being sensitized to the needs, circumstances and realities of SGMs and voiced a desire to be taken seriously by medical staff. At a structural level, interviewees recognized the challenges of finding time within the existing system. Support from health insurance providers and an increase in the number of healthcare professionals could alleviate some of this strain.

The health and well-being of SGMs are shaped by a myriad of factors, including social, cultural, and institutional contexts. Until recently there has been a notable lack of data on the healthcare experiences of SGMs in Austria. Our survey sheds light on the various challenges and disparities they face within the healthcare system in Austria.

Despite limitations, such as the lack of a representative sample due to the unknown population of SGMs in Austria, our findings reveal significant insights into their health status and experiences.

In terms of their mental health, a substantial proportion of respondents reported experiencing depression, anxiety and suicidal thoughts. Discrimination within the healthcare system was a pervasive issue, with reports of treatment being denied, pressure to undergo specific procedures, and humiliation. Such experiences contribute to a lack of trust in and avoidance of healthcare services, further exacerbating health disparities.

However, amidst these challenges lie opportunities for improvement. Recommendations stemming from the interviews emphasize the importance of inclusive practices within healthcare settings. Suggestions included providing inclusive forms for patient registration, incorporating subtle queer symbolism to create a welcoming environment, and sensitizing healthcare professionals to the needs of SGMs. Ultimately, fostering a culture of respect, understanding, and inclusivity within healthcare settings is essential for ensuring the health and well-being of SGMs.

In conclusion, our report highlights the pressing need for targeted interventions and policy changes to address the disparities and discrimination faced by SGMs within the healthcare system. By implementing inclusive practices and structural reforms, we could create a healthcare environment that preserves the dignity and rights of all individuals, regardless of their gender identity, sexual orientation or sex characteristics.

We would like to thank our co-authors Richard Pentz, Lukas Teufl and Roman Winkler for their invaluable contribution to the LGBTIQ+ Health Report and for their productive collaboration. Our gratitude also goes to the group of experts who made significant contributions to the LGBTIQ+ Health Report 2022: Advice Center Courage, Queer Base, TransX, Venib – Association for Non-Binary People, HOSI Salzburg, and VIMÖ – Association of Intersex People Austria and the Universities of Applied Sciences Vorarlberg and Technikum Wien, the Competence Group for Sexual and Gender Diversity at the Austrian Society for Public Health, and Gender Medicine & Diversity at the Medical University of Innsbruck.

¹ Although LGBTIQ+ is used in the title of the report, SGM is the more inclusive term.

² These percentages include the response categories 'frequently' and 'sometimes'.