Introduction

Research conducted in many countries indicated that the prevalence of lesbian, gay, bisexual, transsexual, intersex (LGBTI) individuals in society is 5-8% (1,2,3,4,5). However, the real figures may be much higher than this. There are two main reasons for this discre-pancy in data. The first one is the fact that sexual pre-ferences are not clear-cut and span a much wider range. The second one is, due to society’s homophobic attitude, many people prefer to remain undisclosed.

Although LGBTI individuals may have similar health requirements as their heterosexual peers, they also should be monitored for some health problems they are at risk. Various studies show that LGBTI individuals have higher rates of depression and suicidal tendencies, smoking, alcohol consumption, and substance use than heterosexuals.(6,7,8,9,10)

Although lesbian/gay or transgender individuals comprise a group that should benefit from health care, discrimination is also prevalent in health care. The ne-gative attitude of health care workers and, the careless and disrespectful treatment methods, the prejudiced approach concerning the reasons behind the ailments, reluctance to treat and the fact that LGBTI individuals are generally unaware of their existing health problems all are parts of an extensive network of difficulties.(11)

Research related to disparities in the access or qua-lity of health care among LGBTI adults remains very limited. A study analyzing the articles published bet-ween 1950 and 2007 concerning LGBTI individuals found that of the majority of 21,728 articles, the largest share (31.78%) was devoted to HIV/AIDS and other sexually transmitted infections (STIs). However, besides there was an overall lack of emphasis on general health topics or common causes of mortality.(12)

The prevalent social perspective in Turkey is that any sexual orientation other than heterosexuality is a perversion. There is a tendency to consider them to be an act of indecency, and therefore, many LGBTI individuals suffer discrimination socially, economically, and in many other aspects.(13,14,15)

Consideration of that different sexual orientations may be an illness or a deviation from normal is a paradox that has damaged the health of LGBTI individuals in Turkey. This probably may result in a gap between the health needs of these people and the healthcare services they received. Another consequence is that there is a significant obstacle preventing research in this topic since LGBTI individuals choose not to disclose their sexual orientation because it is forbidden in a large part of society.

On the other hand, people who try to do research in this area most of the time stigmatized, and it may be a problem to get necessary permissions from the authorities. So it is almost impossible to have a sample easily from LGBTI individuals. Nevertheless, there are few but important studies in Turkey concerning LGBTI individuals, but there are no studies concer-ning health care use. The aim of this study is to focus on health care use, illustrate the difficulties, preferences and experiences of LGBT individuals in Turkey.

Method

Study Design: This descriptive qualitative study explores the experiences of LGBTI people on health care usage. The reason for that was because personal stories obtained in qualitative research can be powerful tools with which to address health disparities among LGBTI people.(9,16)

Selection of study subjects: Since we were aware of the difficulties of reaching the LGBT individuals, we have an announcement at the web site of the Pink Triangle Association, which is established by LGBT persons. Initially, we contacted five activists than we reached the rest of the participants by using the snowball method among the purposeful sampling methods. Qualitative method: Since the focus group provides “a more natural environment than that of the individual interview because participants are influencing and influenced by others- just as they are in real life” we used the focus group method.

LGBTI individuals differ both in health problems and attitudes towards the healthcare system based on their sexual orientation. Some of the focus groups consisted of individuals with the same orientation, and some of them were mixed. All the participants were LGBTI individuals. The characteristics of the focus groups are provided in Table 1. All participants gave informed consent. A total of 10 females, 11 males, and 11 trans-females with a mean age of 28 (min 20 – max 45) participated in focus groups. Occupations were divergent such as student, self-employed, sex worker, and doctor.

Data collection: The research team developed focus group questions, drawn up to answer the research question. These questions were open-ended questions concerning their experiences and perception of the health care they had received. The precise formulation of these questions was discussed thoroughly by the research team until mutual agreement and piloted in a first focus group.

Although three of the researchers participated in all focus groups, the interviews were conducted by (DG) who had experience in qualitative research and also teaching qualitative research postgraduate students. An observer (SB) gathered information on the non-verbal communication and the interaction between participants. In this way, special attention could be given in the analysis, to those pronouncements and text fragments where verbal and non-verbal consensus existed (DC). Followed and mapped the conversations to determine the interaction among the group members. The duration of the discussions was limited to 90 minutes.

At the end of every focus group, there was a debri-efing between moderator and observers to discuss the most important themes and possible differences with other focus groups. After no new themes emerged from the focus groups, content saturation was supposed to be reached. The first focus group served as a pilot. Since no indistinctness concerning the questioning or other procedures were allocated, and since the results were very similar to the other focus group interviews, we decided to include these first results into the analyzing process.

All the interviews were recorded and then transcribed for content analysis. Two researchers (DG and SB) independently performed the initial coding. In the case of disagreement, a solution was found by clarifying individually the meaning of the code and discussing until mutual consent was reached. NVivo8 software is used for computer aid. A first draft with the results was sent to all participants for agreement on content and comprehensiveness (response rate 45,4 %). We did not obtain disagreement or additional comments. The ethical permission for the study was obtained from the Izmir Dokuz Eylül University Non-Interventional Studies Ethical Committee on 15.08.2013.

Results

The Health Care Environment

Health care facilities, procedures are prepared considering the gender. When people notice individuals with different sexual orientations, they react in various ways; they stare curiously or avert their eyes, ridicule, or sometimes even abuse them.

“… For example, when we go to the hospital, we generally look like women. However, the guy at the registration take a look at my ID and then says my name out loud-or even announces it on the public announcement system. At that moment everyone in the waiting room turns to look at me. Wow, it’s a man who is just like a woman, and his name is a male name..!”

“To get an exemption report for the military service, you undergo a physical examination…Five of us entered the room. They’re asking: what’s your problem? And I said to the doctor (he softly spells it out)I have a problem because of my sexual orientation…..they took me and placed me under observation for four days, I said I got half day permission from my job to come here…how am I going to explain this four-day absence.”

LGBT individuals claim there are differences in attitudes among health personnel. Sometimes, in some places, they are given priority to prevent difficulties. This and the fact that physicians do not judge them are cited as positive experiences. However, they also experience derision, evasion, and refusal to treat. They believe that being in a risk group as an LGBTI person is used as a labeling mechanism.

“Why is the focus on the homosexual guy (as risk groups for AIDS)? …. if we are advising people to use protection, urging them to use condoms, then this too should change. However, still registering them as a risk group is labeling homosexuality in another way.”

Psychiatrists play an important role in LGBT individuals’life. Almost all of them have a psychiatry consultation for their sexual tendencies, and it almost always happens with parental pressure. The physician’s attitude and approach to homosexuality play a key role for both the individual and his family. When physicians do not consider homosexuality to be a disease and share it with the family “…those words coming from the doctor’s mouth are what prevent the family-as a tribe from killing my friend.”

Health Care Utilizing Behavior

Concerns about the health care system differ according to sexual orientations. While lesbians mainly express displeasure with the overall health care system in general, transgender people claim sexual discrimination.

“Like, there’s a different situation here, like gays and lesbians can hide themselves a bit more. They have many problems too. I know this. But our problem is quite different. Generally, we experience problems because of visibility.”

LGBTI individuals prefer private institutions to public ones and larger health institutions to small ones. This solution is especially applicable to those individuals who cannot hide their sexual orientations. Those who can disguise themselves choose this path when they feel their health problems are related to their sexual orientations.

“When you apply to a private institute, you are a client. I can complain about encountering homophobia or getting bad treatment. I can even argue with him. I can talk to customer services at the hospital.”

However, private health care costs them a lot. Therefore LGBTI individuals use some other alternatives for health care, such as peers, internet, television (TV) programs, and popular magazine publications, even for STDs, which they should immediately consult a doctor. These sources have been chosen because they are cheap, easily accessible without being registered. From these sources, they can obtain information ranging from knowledge about diseases to the names of doctors or pharmacies that will treat them well.

Another reason for using these sources is to protect themselves from possible adverse reactions and consequences. The initial information concerning what they may face also determines which health facility they will choose. They see themselves at risk for HIV and STDs and are hopelessly afraid of the consequences of these diseases. Because, being labeled or stigmatized not only brings the problems concerning the illness itself, but also can endanger the person’s job, his social standing among his peers, and can lead to alienation in all strata of society.

“… a close friend of mine who is a homosexual sex worker, felt some lumps on her neck, some wart-like things in her genital region. She was exhausted, so first she checked on the internet because she was afraid to go straight to the doctor. And since she was almost sure she had caught an STD, she didn’t even want to tell her friends because she was frightened of being outcast since she worked at a night club, she was afraid that if her bosses heard she would be fired. Finally, when she couldn’t stand it any longer, she went to the doctor and found out that she had syphilis.”

They continuously face a dilemma in their relations with physicians. On the one hand, they fear that if they disguise their sexual orientation, they may receive incorrect or insufficient health care. On the other hand, they are afraid of the reactions they might get if they disclose their sexual orientation.

“I dunno, for example there may be a fungal problem or an allergy and you go to the doctor. But the doctor has to know that you are a lesbian for the real problem to be understood. Maybe it is something that is sexually transmitted. And maybe you can’t get the right treatment because you haven’t spoken up.”

The Consequences of the Health Care Utilizing Behavior

The reluctance to seek health care has led to unresolved health problems which can be exacerbated. They have so many unmet health needs due to their sexual orientation.

“Sometimes, like when watching TV or when it’s mentioned here and there, I get the idea… a little that we should have it done (HIV test), my mind …. a little, but I really dunno much about who to or where to go…”

“We do enemas very often so sometimes we don’t go out without doing one. But we don’t have any problems like not being able to retain our feces. But protection is really important and there is no apparatus for lesbians. There is abroad but, it’s almost impossible to find in Turkey.”

“Some people take the hormone in order to put on weight, others to lose it. Like, he says my leg has dropped, so he goes some hormones, my hair is falling out, so he goes and pops some hormones, but like, too much hormones can harm the body probably and can cause cancer after some time, or at least that’s what I know (the doctor will inform), nope, just like there isn’t any, no girl knows what to do with them anyways.”

When the issue of healthy aging is mentioned, they react sarcastically and say that they don’t think they will make it that far. Here it must be said that they are referring to becoming victims in murders related to homophobia

“Actually, there are really very few among us who can age. Like, when they started, there were perhaps 500-600 of them, but when they reached 60, there were only three of them left.

Another consequence of rejecting public health care services was being open to abuse and cheated.

“So when you find someone who treats you decently, or smiles when they serve you, you tend to believe they’re nice. There are a lot of things like dietary supp-lements or medications on the market, and the pharmacist naturally earns a lot by selling them. Me for examp-le, I have spent tons of money on pharmacies I know well. I don’t go to the doctor; I go to the pharmacy… It’s a commercial thing. Totally so…”

Discussion

Turkey has not signed international regulations and on a national basis, there are no legal regulations protecting LGBTI individuals from sexual discrimi nation.(17) In contrast, the existing laws are interpreted and implemented to the disadvantage of LGBT individuals. The widespread prevalence of homophobia in the society is reflected among health care workers.(18,19) which results in LGBTI individuals to avoid seeking health care(20,21) as it is shown in our study.

This situation also impacts and prevents contact which is one of the most important methods to overcome homophobia. The fact that LGBTI individuals choose to disguise their identities makes it difficult for physicians to become aware of both their own prejudices and the existing deficiencies in the system. The lack of exposure also causes alienation from the subject .(22)

Cultural differences in the recognition and interpretation of symptoms and in the use of health services are the subject of a rich literature.(23) In this study, the participants developed their attitudes and behaviors according to experiences they had not faced personally. For example, all the participants were reluctant to disclose their sexual orientation to the physician even though some had not experienced homophobia on a firsthand basis. Most of their attitudes have been shaped by common experiences rather than personal ones, and thus they act accordingly. The role of these general presumptions appears to be significantly important when seeking care in health services.

In our study, the turning point for LGBT individuals governing their choices to seek health care is their resolving the dilemma of whether or not to disclose their sexual identity, as it was in other studies.(24,25,26) On the other hand, disguising don’t provide complete protection. Whatever rejected transgender people feel about sex-change procedures, the same rejection and discomfort apply for lesbians about receiving treatment for STDs, even though they are comfortable about seeking help for many other complaints.

As a consequence of limited and inappropriate access to health services, LGBT individuals fall behind in both determining the risks pertaining to age groups, family histories, lifestyles, and getting health care for some problems more prevalent and specific for them. International studies have found the life expectancy of gay men to be up to 20 years less than their hete-rosexual counterparts and have some different issues related to aging(27,28,29) or a higher risk for breast and gynecologic cancers may exist in lesbian populations.(30,31) Not only do they not have sufficient information about issues related to their own health, but also they cannot benefit from health care available to the public, in general, such as adult vaccinations, periodical health examinations, and smear tests.

In our study, LGBTI individuals believe that being a “homosexual” is not in itself a risk factor, but indul-ging in risky behaviors is. However, even if homosexuals declare they have not engaged in suspicious acts, they are rejected, and this is perceived as one example of discrimination. Physicians consider LGBT individuals to be a risk group whether or not they indulge in risky sexual behavior.(24) Our study also showed that the fear of being labeled and stigmatized prevents LGBT individuals from having the HIV test done even if they put themselves at risk by not doing so. This situation also increases the spending of social resources on preventable health conditions.

Internet, peers are important alternatives for getting health information for LGBT individuals. Studies have shown that LGBT youth rely on the internet and related technologies to a higher degree than their peers in order to find an accepting peer group and social support.(32) Sites offering the correct information and implementing methods such as establishing an effective online doctor-patient interaction might be valuable tools for expanding this field. Since peers are considered as another reliable source, peer education can be used for dissemination of information in the LGBT community.

Conclusion

LGBTI individuals claim that because they are apprehensive about disclosure and discrimination, they cannot fully benefit from health services and tend to seek alternative care. This result prevents them from receiving their proper health care and utilizing preventive health care. The existing health care regulations in Turkey cause difficulty for, and physicians are uninformed concerning the needs of LGBT individuals.

The Strengths and Weaknesses of the Study: Due to the complicated and vast quantity problems of the LGBTI community, participants frequently had difficulties in concentration while answering the questions during the interviews. Our attempts to focus on health care utilization occasionally caused us to ignore some of their very valuable contributions.

• Grulich AE, de Visser RO, Smith AMA, RisselCE, Richters J. Sex in Australia: Homosexual experience and recent homosexual encounters. Aust N Z J Public Health 2003;27:155–63.Grulich AE, de Visser RO, Smith AMA, RisselCE, Richters J. Sex in Australia: Homosexual experience and recent homosexual encounters. Aust N Z J Public Health 2003;27:155–63.
• Layte R, et al. The Irish study of sexual health and relationships. Crisis Pregnancy Agency. 2006. http://www.lenus.ie/hse/bitstream/10147/122326/1/CPAISSHRMainReport.pdf Retrieved 13 January 2014.
• Smith AM, Rissel CE, Richters J, Grulich AE, de Visser RO. Sex in Australia: sexual identity, sexual attraction and sexual experience among a representative sample of adults. Aust N Z J Public Health. 2003;27:138-45.
• Integrated Household Survey April 2011 to March 2012: Experimental Statistics http://www.ons.gov.uk/ons/rel/integrated-household-survey/integrated-household-survey/april-2011-to-march-2012/stb-integrated-household-survey-april-2011-to-march-2012.html. Retrieved 13.01.2014
• Gates JG. How many people are lesbian, gay, bisexual, and transgender? http://williamsinstitute.law.ucla.edu/research/census-lgbt-demographics-studies/how-many-people-are-lesbian-gay-bisexual-and-transgender/ retrieved 13.01.2014
• Herek GM, and Garnets LD. Sexual orientation and mental health. Annu Rev Clin Psychol 2007;3:353-75.
• The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Institute of Medicine, The National Academies Press: Washington DC, 2011.
• Meyer IH, Dietrich j,  Schwartz S. Lifetime prevalence of mental disorders and suicide attempts in diverse lesbian, gay, and bisexual populations. Am J Public Health 2008;98:1004-6. 
• O’Donnell S, Meyer IH, Schwartz S. Increased risk of suicide attempts among black and latino lesbians, gay men and bisexuals. Am J Public Health 2011;101:1055-59.
• Cochran SD, Mays VM, Alegria M, Ortega AN, Takeuchi D. Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults. JConsul Clin Psychol 2007;75:785-94.
• Pan American Health Organization and World Health Organization. 2013. https://www.paho.org/hq/index.php?option=com_content&view=article&id=9056:2013-health-authorities-pledge-access-health-care-lgbt-people&Itemid=1926&lang=en
• Snyder JE. Trend analysis of medical publications about LGBT persons: 1950–2007. JHomosex 2011;58:164-88.
• Kutlu DC. Discrimination in working lıfe: Sample of gay workers. Symposium of Social Exclusion and Social Services-2009, Ankara. 
• Ozturk MB. Sexual orientation discrimination: Exploring the experiences of lesbian, gay and bisexual employees in Turkey. Human Relations 2011;64:1099-118.
• Oksal A. Turkish family members’ attitudes towards lesbians and gay men. Sex roles 2008;58:514-25
• Mays N, Pope C. Qualitative research in health care. Assessing quality in qualitative research. BMJ 2000;320: 50–2. http://www.rainbowhealthontario.ca/admin/contentEngine/contentDocuments/ Qualitative_Research.pdf. retriewed 14.01.2014
• Not an illness nor a crime: Lesbian, gay, bisexual and transgender people in Turkey demand Equality. Amnesty International Turkey Report, 2011. www.amnesty.org/…/eur440012011en.pdf   retriewed 14.01.2014
• Lyn I. Homophobia and heterosexism: implications for nursing and nursing practice Aust J AdvNurs 2007;25:70-6.
• Smith DM, Mathews WC. Physicians’ attitudes toward homosexuality and HIV: survey of a California Medical Society- revisited (PATHH-II). J Homosex 2007;52:1-9.
• Van Dam MAA, Koh AS, Dibble SL. Lesbian disclosure to health care providers and delay of care. JGLMA 2001;5:11-9.
• Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. J Amer Med Assoc 2011;306:971–7.
• Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients.  Fam Med 2006;38: 21-7.
• Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J. Culturally competent healthcare systems: a systematic review. Am J Prev Med 2003;24:68-79.
• Rispel LC, Metcalf CA, Cloetec A, Moormand J, Reddyesık V. You become afraid to tell them that you are gay: Health service utilization by men who have sex with men in South African cities. J.Public Health Policy 2011;32:137–51.
• Heck JE, Sell RL, Gorin SS. Health care access among individuals involved in same-sex relationships. American Journal of Public Health 2006;96:1111-8. 
• Diamant AL, Wold C, Spritzer K, et al. Health behaviors, health status, and access to and use of health care: A population-based study of lesbian, bisexual, and heterosexual women. Arch Fam Med 2000;9:1043-51.
• Hogg RS, Strathdee SA, Craib KJ, O’Shaughnessy MV, Montaner J, Schechter MT. Modelling the impact of HIV disease on mortality in gay and bisexual men. Int J Epidemiol 1997:26:657-61. 
• Frisch M, Brønnum-Hansen H. Mortality among men and women in same-sex marriage: a national cohort study of 8333 Danes. Am J Public Health 2009;99:133-7.
• Wagenena AV, Driskellb J, Bradfordc J. “I’m still raring to go”: Successful aging among lesbian, gay, bisexual, and transgender older adults. J Aging Stud 2013; 27: 1–14.
• Case P, Austin SB, Hunter DJ, Manson JE, Malspeis S, Willett WC, et al. Sexual orientation, health risk factors, and physical functioning in the Nurses’ Health Study II. J Women Health 2004;13:1033-47.
• Brandenburg DL, Matthews AK, Johnson TP, Hughes TL. Breast cancer risk and screening: a comparison of lesbian and heterosexual women. Women Health 2007;45:109-30.
• Magee JC, Bigelow L, Dehaan S, Mustanski BS. Sexual health information seeking online: a mixed-methods study among lesbian, gay, bisexual, and transgender young people. Health Educ Behav 2012;39:276-89.