“IT ERASES PIECES OF YOU”: HOW IDENTITY SALIENCE “CUTS BOTH WAYS” FOR LGBTQ+ INDIVIDUALS IN HEALTHCARE ENCOUNTERS By Andrew N. Kirks-Cler A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Sociology—Master of Arts 2023 ABSTRACT Despite a recent influx of literature surrounding LGBTQ+ health disparities, few scholars have examined how different identity statuses become relevant or invisibilized within healthcare settings, or how identity salience in medical spaces influences the healthcare experiences of marginalized individuals. Drawing on 41 semi-structured interviews with LGBTQ+ people, I use concepts from sociological and social-psychological identity theories to frame the question: how do sexual and gender minorities describe their experiences with primary, mental, and specialist healthcare services? Specifically, which identities become salient across different healthcare contexts, and what are the related consequences of identity salience or erasure for LGBTQ+ patients? My findings suggest that LGBTQ+ individuals must navigate intersecting layers of discrimination in healthcare spaces, the experience of which varies depending on which identities are made salient through their interactions within healthcare spaces. Both visible and invisible identities had the potential to become salient via conversations with providers, health screenings, interactions with romantic partners, and more. At times, the identities that providers ascribed to patients were misaligned with patients’ own claimed identities. In other instances, provider-ascribed and patient-claimed identities did align; however, ideas about which of these identities should become most salient during a healthcare encounter, when, and how, differed between patients and their providers. Both of these experiences contributed to reports of negative healthcare experiences for LGBTQ+ patients. This work contributes to health, gender, and sexuality scholarship by highlighting mechanisms that promote healthcare inequalities for sexual and gender minorities, which remain a persistent concern in all three fields of scholarship. Overall, evidence suggests that LGBTQ+ people’s experiences of healthcare are characterized by a constant negotiation of priorities, desires, needs, self-advocacy, and personal identities. This thesis is dedicated to my beloved cat, Mister Louis Kuitton. May he perch on my keyboard for many more papers to come. iii ACKNOWLEDGEMENTS I would like to extend my most sincere gratitude to each of the phenomenal individuals who made this project possible. A million thank-yous to my Committee: my Chair, Dr. Stef Shuster, to whom I owe absolutely everything—from successful conference talks, to opportunities for conducting rigorous health research, to learning how to write again, I would not be able to call myself a scholar without Stef’s profound guidance; Dr. Ning Hsieh, whose extensive expertise motivates me to pursue, restlessly, the acquisition of knowledge; Dr. Soma Chaudhuri who, in the face of great personal tragedy, assured me that I would graduate, and who bolstered that prophecy with her unyielding support; and Dr. Carla A. Pfeffer, whose own brilliant scholarship has inspired an entire Google Drive of future research ideas. Thank you, also, to my honorary fifth Committee member Dr. PJ Pettis, for graciously offering such detailed feedback throughout the writing process. I am endlessly grateful to my cohort mates, Sam and Hannah, for consistently reminding me of our collective passion for community and our inextinguishable drive to make meaningful difference with our work; this thesis exists as a direct result of their support. Thank you to every mentor and scholar and colleague I’ve met whose excellence has fueled me to this point. Finally, to the queer little family I’ve gathered over the years: You know who you are, and I cherish you. Every success, I owe to the inspiration you spark within me, today and always. iv TABLE OF CONTENTS INTRODUCTION........................................................................................................................... 1 BACKGROUND............................................................................................................................. 4 METHODS...................................................................................................................................... 9 RESULTS.......................................................................................................................................14 CONCLUSION..............................................................................................................................30 REFERENCES.............................................................................................................................. 34 v INTRODUCTION Previous scholars have documented how gender and sexuality structure social interactions (e.g. Schilt & Lagos, 2017; West & Zimmerman, 1987), educational experiences (e.g. Mollborn & Everett, 2015; Pascoe, 2011), and family dynamics (e.g. Acosta, 2013; Meadow, 2018; Pfeffer, 2017). Recent studies have also evaluated the health experiences of BIPOC LGBTQ+ populations, with results showing that, compared to their white peers, LGBTQ+ people of color experience fewer financial resources (Badgett, Choi, & Wilson, 2019), increased minority stressors (Green, 2008), greater disparities in access to healthcare (Hsieh & Ruther, 2017), and worse self-reported physical and mental health (Streed, McCarthy, & Haas, 2018). While current scholarship has begun to document the persistent health inequalities that BIPOC and LGBTQ+ communities experience, fewer studies examine how intersecting identities become salient across different healthcare encounters. Identity salience describes the likelihood of a particular identity being made personally or interactionally relevant across different social contexts (Stryker, 1968). Existing research surrounding identity salience has found links to social inequality (Hunt, 2003; Ridgeway & Markus, 2022) at the personal, interactional, and cultural levels (Callero, 2014), including economic stratification (Ghatak & Verdier, 2023) and political violence (Øtsby, 2013). Recent health research has also identified relationships between identity salience and mental health outcomes (McLeod, 2015) as well as disparities in self-rated health (Lagos, 2019). A gap remains, however, in examining how identity salience informs interactions that occur within medical spaces in ways that contribute to broader health inequalities for LGBTQ+ individuals. To begin filling this gap, the present study asks: how do sexual and gender minorities describe their experiences with primary, mental, and 1 specialist healthcare services? Which identities become salient across different healthcare contexts? And what are the related consequences of identity salience or erasure for queer patients? Drawing on 41 semi-structured interviews with LGBTQ+ people, I examine the circumstances under which particular identities become salient, and the consequences of such processes, across healthcare contexts. My findings suggest that LGBTQ+ individuals must navigate intersecting layers of discrimination in healthcare spaces, the experience of which varies depending on: 1) which identities are made salient through their interactions within healthcare spaces, and 2) whether provider assumptions surrounding patient identity salience align with the patient’s own self-concept. The highly contextual and oft unanticipated nature of identity salience within healthcare encounters meant that LGBTQ+ individuals were generally caught off guard by the conclusions providers voiced about them based on their perceived social identifiers, which sometimes did, and sometimes did not, align with participants’ actual reported identities. Specifically, I identified four major consequences of identity salience within LGBTQ+ healthcare encounters: 1) Visually salient identities became a primary reference point from which providers appeared to draw assumptions about patients; 2) Patients often anticipated prejudice from providers based on their salient marginalized identities, which contributed to healthcare delays or avoidance; 3) Patients often expressed a need to educate their providers about their marginalized identities; and 4) Individuals reported dissatisfaction when they felt that providers had overlooked their self-determined salient identities in favor of more visibly salient identifiers. The findings offered here make advancements in three areas of scholarship. First, I seek to fill a gap in current sexual and gender minority health literature by using in-depth interview data with 41 LGBTQ+ BIPOC individuals to examine how their reported healthcare experiences 2 related to their salient social identities. Second, this study furthers scholarly discussions surrounding the contextual nature of identity salience by examining the social and medical consequences of different identities becoming salient at varying points across healthcare interactions. Finally, existing sexual and gender minority health research has disproportionately examined the experiences of white individuals, thereby limiting scholarly knowledge of intersecting social identities. As I demonstrate, the intersection of identities is integral to shaping the experiences of marginalized populations (Crenshaw, 1980). While participants’ individual marginalized identities shaped their healthcare experiences, they did not do so in isolation from one another; rather, it was the explicit interaction between people’s multiplicity of identities that influenced their health behaviors and outcomes, medical decisions, interactions with providers, and overall well-being. 3 BACKGROUND LGBTQ+ Health Disparities Minority stress theories of health posit that individuals holding marginalized identities are more likely to experience distal stressors, such as prejudice and discrimination, which lead to proximal stressors, such as fear of rejection, rumination over past prejudice, and anxious-depressive symptoms (Meyer, 2003; 2007). Minority stressors correlate with adverse health outcomes for marginalized individuals (Link & Phelan, 2001; Paz & Ramirez, 2019; Turner & Avison, 2003). Emerging scholarship has begun to examine explicit links between minority stress and the experiences of sexual minorities (Alessi, 2014; Goldbach, 2014; Meyer, 2013) and transgender and gender nonconforming individuals (Rood et al., 2016; Smart et al., 2020), and consistently finds that minority stress events—like experiences of prejudice, stigma, lack of supportive environments, psychological stress, and internalized homophobia/transphobia—have a negative cumulative impact on the health of LGBTQ+ individuals. The increased prevalence of negative health outcomes for LGBTQ+ people who experience minority stress is particularly concerning when considering the growing body of scholarship that demonstrates how LGBTQ+-related stigma significantly contributes to sexual and gender minorities’ disparate avoidance and delayal of medical care compared to heterosexuals and/or cisgender people (Cruz, 2014; Gates, 2014; Hsieh & Ruther, 2017; Kcomt et al., 2020; Skopec & Long, 2015; Ward et al., 2014; Willging et al., 2019). Studies show that sexual and gender minorities commonly delay medical care because they feel that providers are not knowledgeable about their specific healthcare needs (Agenor et al., 2015; Cruz, 2014; Kattari et al., 2021; Poteat, German, and Kerrigan, 2013) and may be unwilling to listen to and learn 4 about them (Baker & Beagan, 2014). Providers’ lack of knowledge surrounding their LGBTQ+ patients’ identities exposes those who are visible as sexual/gender minorities to external stigma in their healthcare encounters, while those who are not “out” experience internalized stigma (Cruz, 2014) and isolation from fellow members of their community (Bucci, 1995; D’Augelli, & Grossman, 2001; Frable, Platt, & Hoey, 1998; Smart & Wegner, 1999) which further exacerbates health disadvantages (see Smith & Christakis, 2008). When LGBTQ+ people do seek care, they often experience medical mistreatment in the form of misgendering (Paine, 2018; Shuster 2016); invasive questions and unnecessary procedures (Venetis et al., 2017); insurance discrimination (Bakko & Kattari, 2021; dickey et al., 2016); and cultural insensitivity (Giffort & Underman, 2016); as well as prejudice, refusal of treatment, and disrespectful interactions (Davis et al., 2016; Sabin, Riskin, & Nosek, 2015). These experiences are linked to heightened risk for chronic health issues that might otherwise have been prevented (Hendricks & Testa, 2012; Hughto et al., 2015; Meyer, 1995). For example, population-based studies reveal that LGBTQ+ individuals are at higher risk than their non-LGBTQ+ peers of developing substance use disorders, attempting suicide, and experiencing mental illness (Burgard et al., 2005; Cochran & Mays, 2000; Gillman et al., 2001; Meyer, 2003; National Academies of Sciences, Engineering, and Medicine, 2000; Surace et al., 2019). Inattention to the unique needs and experiences of marginalized patients contributes to a “one-size-fits-all” approach to medical care. Within this model, individuals possessing normative social identities are prioritized, while marginalized patients’ needs are neglected, which has been associated with high rates of patient dissatisfaction and medical avoidance (Gilbar & Miola, 2015), particularly among sexual and gender minorities (Agenor et al., 2014; Dahlhamer et al., 2016; Hsieh & Ruther, 2017). “One-size-fits-all” care is primarily informed by dominant cultural 5 scripts, the ubiquitous nature of which means that medical providers tend to draw on them even unintentionally in their attempts to evaluate individuals they find unfamiliar in their standard clinical routines (Shuster, 2021). As we suggest, this practice may be inefficient in healthcare interactions with LGBTQ+ individuals, as their marginalized identity statuses inextricably influence their health behaviors, treatment needs, and interactions. Yet, missing from extant scholarship is an evaluation of how the salience of various patient identities can differentially inform the healthcare experiences of LGBTQ+ individuals, particularly in their encounters with medical providers. Identity Salience Placed within a structural-symbolic interactionist perspective, identity theory is crucial to understanding the healthcare experiences of LGBTQ+ people, as it delineates the circular means by which society impacts understandings and constructions of self-concept, which impacts social behavior (Mead, 1934; Owens, 2010; Stryker, 2008). Identity salience refers to the different contexts under which a given identity might be invoked or “activated” in social interactions (Stryker, 1968; Stryker & Serpe, 1982). Existing scholarship has demonstrated how links between identity salience and personal, interactional, and cultural systems of stratification (Callero, 2014) contribute to health inequalities for marginalized groups (Lagos, 2019; McLeod, 2015). How identities become activated in interactions is partially dependent on one’s self-concept or self-referring dispositions, like attitudes, traits, values, and abilities; physical characteristics, like weight, height, and deafness; and identities (Rosenberg 1979, pp. 15-17). Four key sources of identity characterization include: 1) personal or individual identity (e.g. “I am John Doe. I was born June 4, 1980 to my mother, Jenette Doe.”); 2) role-based identity (e.g. 6 “I am a teacher and this is my student.”), whether determined by recurrent interactions with related social actors (Thoits, 1995) or an individual’s “imaginative view of himself as he likes to think of himself being and acting” in specific social positions (McCall & Simmons, 1966, p. 67; emphasis in the original); category-based identity (e.g. “I am a Jewish American that is active in my religious community.”); and group membership-based identity (e.g. “I am an official member of the U.S. Girl Scouts.”). However, distinctions between these four sources of identity are often blurry and do not always sufficiently explain how identities organize and motivate actions across social contexts (Burke, 2004; Smith-Lovin, 2007). Therefore, while acknowledgement of these identity sources is helpful in understanding relevant discourse within the existing identity literature, what is less understood is how social interactions influence which identities are recognized and validated—or not—within healthcare contexts, and to what consequence. While scholars have recognized how “stable, internalized aspects of social identities are formed and how they affect behavior as the social actor moves from one situation to the next” (see Burke, 1991; Stryker, 1968) there remains ambiguity in how different social contexts draw out specific identities and actively mold their meanings (Tajfel, 1979). What is documented is the reciprocal relationship between contexts and identities, wherein scholars have found that identities tend to be organized hierarchically by the relative value they have in influencing an individual’s overall conception of their ideal self (McCall & Simmons, 1966, pp. 76-80). Moreover, individuals are more likely to work to represent identities ranked more highly in their own value hierarchy. Stryker’s concept of identity salience describes the likelihood of a particular identity actively being invoked in social interactions at any given time (1968; 2008). A growing body of research has called attention to sexuality and gender identity salience in educational spaces (Hughes & Hurtado, 2018) and athletics (Cunningham, 7 2013), as well as across other social-relational contexts including family relations, friendships, neighborhoods, religious communities, work, and online interactions (Keene, Heath, & Bouris, 2022). Related research captures situations wherein gender identity was ascribed to trans and gender nonconforming people. For example, Lagos’ work examined how people were ascribed a gender identity based on their vocal register; she found that individuals whose assigned identities did not match their self-identified gender reported poorer health outcomes (Lagos, 2019). Additionally, Lagos’ findings are relevant because they highlight how personal identities can be overlooked or overridden by external identity designations, such as those ascribed by healthcare professionals. People tend to experience improved well-being when they feel they have performed a desired social role successfully, and when they feel they have failed to perform their desired social role within its related context, they often experience poorer health (Shuster & Bodenheimer, 2021). To the best of our knowledge, few sociological studies have examined LGBTQ+ identity salience within healthcare settings. Therefore, the present study seeks to expose links between moments when particular identities become salient in medical encounters—via patient disclosures or provider assumptions—and individual health outcomes for LGBTQ+ patients. 8 METHODS To examine how identity salience influences healthcare encounters across medical contexts, I draw on 41 in-depth interviews with a diverse sample of LGBTQ+ individuals. Interviews ranged from one to two hours in length. Because the interviews were conducted during the height of the Covid-19 pandemic, when social distancing guidelines were in place, all interviews were conducted online via voice or video call. The virtual nature of our interviews did lend some benefits; for example, interviewees were able to participate in the study from the comfort of their homes or other preferred locations. Furthermore, conducting interviews online meant that all conversations could easily be recorded and transcribed verbatim. Each participant received a digital e-gift card to compensate them for their time. The IRB at Michigan State University approved this research protocol. All names that appear are pseudonyms. All other demographic information and pronouns reflect participants’ stated identities. Interviews were intended to elicit vibrant narrative descriptions of LGBTQ+ experiences of various types of healthcare. After collecting demographic data and establishing rapport, participants were asked how they found healthcare providers in their area and how they learned about local providers. Participants were encouraged to discuss their process of finding primary care providers as well as mental health providers and any specialists (e.g., endocrinology, gynecology, gender-affirming care). They were also asked if they had attempted to find local providers who shared their identity, such as racial, gender, and/or sexual identities, and what that experience looked like for them. These questions were followed by queries regarding participants’ specific experiences with past and present providers, particularly as they related to participants’ salient social identities, moments in health encounters when participants felt that providers were making assumptions about them, and why that may have been the case. 9 Sampling & Recruitment The study originally began with an online survey instrument that was distributed throughout various online LGBTQ+ community spaces in a Midwestern state to assess prospective participants’ sociodemographic characteristics and the self-reported quality of their experiences with physical, mental, emergency, specialist, and gender-related healthcare services and providers. Following the initial survey data collection, members of the research team decided to move toward collecting semi-structured interviews with participants who self-identified as LGBTQ+. For this stage of the research process, the call for study participants stated that researchers were interested in speaking with “people who identify as LGBTQ+.” This call was not limited to any one identity within this broad category. Recruitment first occurred with survey participants who indicated they would be interested in completing an interview. Once the research team completed these interviews, they then used a dual-snowball sampling method, in which the initial round of interviewees was asked to share the call for participants with their networks. The research team—all of whom identify as LGBQ+ and/or trans or nonbinary—sent out the call to their personal networks as well. After completing an interview, interviewees were asked to contact three to five other people on the researchers’ behalf. Additional contacts were made by attending community groups and events across the target state, posting calls for participants in places such as LGBTQ+-owned coffee houses; bars; resource, health, and community centers; as well as on blogs and social media sites. This multi-pronged approach contributed to the diversifying of participants based on race and age. 10 Table 1: Participant Demographics Gender n % Cisgender Woman 17 41 % Nonbinary/Genderqueer 15 36 % Cisgender Man 5 12 % Transgender Woman 2 5% Transgender Man 2 5% Sexuality Gay/Lesbian 15 36 % Queer 15 36 % Bi/Pansexual 10 24 % Asexual 1 2% Race White 19 46 % Black 6 14 % Hispanic/Latino/Latina/Lati nx 6 14 % Indigenous/Native American 6 14 % Asian 4 10 % Age 18-29 16 39 % 30-49 16 39 % 50-64 5 12 % 65+ 4 10 % Education High school or less 5 12 % Some college 7 17 % Bachelors 13 32 % Advanced Degree 16 39 % 11 Our sample consisted of 46 percent women and 17 percent men, with 10 percent identifying as binary transgender women or men. The remaining 36 percent of respondents identified as nonbinary or genderqueer. In terms of sexuality, our sample was split among 36 percent gay/lesbian respondents and 36 percent of participants identifying as queer, with an additional 24 percent of participants identifying as bisexual or pansexual, and 2 percent identifying as asexual. White participants made up 46 percent of our sample, with 14 percent of respondents identifying as Black, 14 percent as Hispanic or Latino/Latina/Latinx, 14 percent as Indigenous/Native American, and 10 percent of participants identifying as Asian. It should be noted that, of our respondents, 10 percent identified with multiple race categories; for the purposes of our demographic table, these respondents were aligned with the racial category that became most salient across a majority of social situations, or that they felt had most influenced their healthcare experiences. Furthermore, as the historic centering of white populations in health research has obscured the experiences of BIPOC LGBTQ+ individuals, LGBTQ+ people with marginalized racial identities were intentionally overrepresented in our current sample (U.S. Census Bureau, 2022). This selective sampling method allowed us to better evaluate the processes of multiple marginalization that BIPOC LGBTQ+ individuals experience in healthcare encounters. Finally, 39 percent of our respondents were between the ages of 18-29 years old at the time of our interviews, 39 percent were between 30-49 years old, and the remaining 24 percent of participants were over the age of 50. All but 12 percent of participants were college educated to some degree. Participation was limited to a Midwestern state for consistency across healthcare policies and practices, as healthcare policies and protections for LGBTQ+ patients vary from 12 state-to-state, and given the current limitations of collecting qualitative data during the COVID-19 pandemic. Data Analysis Interview transcripts were uploaded to the qualitative data analysis program NVivo. The first round of coding was largely inductive, with work being distributed among a six-member research team. Following our initial process of inductive coding, the research team cross-checked one another’s codes and compiled an original codebook consisting of 11 major codes. At this point in the data analysis process, the research team split off into groups, with at least two team members being assigned to each of the 11 major codes: Health Access, Gut Instinct, Health Behaviors, Identities, Impression Management, Institutional Norms, Pandemic, Power Dynamics (Positive/Patient-Centered), Power Dynamics (Negative Consequences), and Emotions. We then re-coded the data, with frequency and depth of discussion of specific themes determining their level of relevance as they appeared in our empirical observations. This re-coding process resulted in the creation of 105 related subcodes. Data for the present article was primarily derived from three major codes—Identities, Health Access, and Health Behaviors—which consisted of 50 related subcodes that I was in charge of using to analyze the data. An additional, overarching theme that I recurrently identified through my coding process was that of Identity Salience, which served as the foundation for the present study. In what follows, I begin to examine the consequences of different identities becoming relevant across various healthcare encounters with LGBTQ+ individuals. 13 RESULTS In examining the healthcare experiences of LGBTQ+ individuals, both visible identities (e.g., other-perceived race, other-perceived gender, assumed socioeconomic class, body shape, and age group) as well as invisible identities (e.g., self-identified race, self-identified gender, and sexual orientation) had the potential to become salient and inform the patient’s experiences in health encounters. For example, Caroline, a white heterosexual trans woman living in a rural town, described how her transgender identity became salient in healthcare interactions following her vaginoplasty, when her primary care provider of over a year continued to persistently misgender her. When asked in a follow-up question whether this provider knew details about her life, family issues, or other causes of stress, Caroline explained that her provider was “adding to the problem.” She elaborated: She wants to not acknowledge me as female. I’m sent out to do OBGYN. Instead of doing it herself, she sent me out. Anything to do with that part, she don’t want nothing to do with it. She refuses me on a lot of things, which I'm not real happy with…She doesn't [acknowledge my concerns]. I don't know why, but she just doesn't. I mean, as far as, like, walking in and taking your blood pressure and stuff like that? She won’t touch me. For Caroline, her gender identity became salient in healthcare interactions when her doctor refused to address her appropriately or provide necessary medical services. While Caroline expressed her gender as a woman, her provider’s failure to acknowledge her womanhood made Caroline’s gender identity less relevant to the healthcare interaction than her transgender identity. In this instance, Caroline’s transgender identity was made salient not by her own volition, but by her provider’s refusal to engage with Caroline’s more hierarchically prominent salient identifiers. The salience of Caroline’s transgender identity was then used as a basis for explicit discrimination in the healthcare space. When we consider the documented connection between an individual’s perception of their role performance as “successful” and their overall self-esteem 14 and wellbeing (James, 1890), we can better understand how the inverse experience—providers failing to acknowledge social roles that patients themselves identify as important—can contribute to negative healthcare reports. Caroline’s experience was not uncommon among LGBTQ+ respondents. Many reported that their marginalized identities were frequently made salient during healthcare interactions in ways that stigmatized, otherized, or informed provider assumptions about them. In what follows, I demonstrate how patients’ identities became salient based on the assumptions they perceived providers making about them, the consequences of which included healthcare delay and avoidance, as well as feelings of frustration from LGBTQ+ people who felt a need to educate providers about their identities. Moreover, the data illustrates how identity salience “cuts both ways” in healthcare encounters, sometimes to the advantage—and more often, to the disadvantage—of LGBTQ+ people’s health experiences. Provider Assumptions Based on Patient Identity Often, respondents reported that they were incorrectly assumed to be cisgender and/or heterosexual across healthcare spaces. For example, Rebecca stated that, “sometimes, it’s uncomfortable to include my partner in my healthcare without [providers] assuming she’s my sister or my mother or a relative of some sort and it's very frustrating.” Frustration was common among LGBTQ+ patients who were assumed to be heterosexual and cisgender during their healthcare interactions, as they felt misrepresented and that they were not receiving the appropriate care given the unique relationship between their marginalized identity statuses and related health outcomes. In these situations, providers made assumptions about patient sexuality and gender identities based on heteronormative social expectations, thus obscuring the patient’s 15 actual marginalized sexuality at the same time that sexuality became their salient identifier within the interaction. In other circumstances, respondents reported feeling profiled based on one or more of their visible identities, which seemed to become the primary lens through which their providers assessed their medical needs. Maru, who identified as a multiracial pansexual non-binary person, explained how their providers’ perceptions of their body size, coupled with their perceived race and gender, interfered with doctors’ ability to assess their other, more relevant measures of health: When they see on my chart that I was born as a female, and that I'm Black…on all of my paperwork—even without my doctors telling me—they put “obese.” They don't even have my weight listed sometimes. Just “obese.” And they just take that and roll with it from what they know before from previous patients. And that doesn't really work. Maru reported dissatisfaction with providers who expressed biases toward them based on past interactions with patients. According to Maru, the medical care they received often proved inadequate because providers used the health patterns of other, separate patients to shape their understanding of Maru’s well-being, rather than making individualized recommendations informed by Maru’s own personal indicators of health. For example, Maru recounted an instance in which their heart condition was incorrectly attributed to their weight (which was not properly recorded in their chart to begin with). The medical misattribution Maru experienced resulted in their discontinuation of necessary cardiac screenings and treatment: In terms of the specialist that I was trying to see, he canceled. I didn't take my medication for, like, two days, and he canceled my heart echo, because I was like, “Yeah, the medicine helps,” and he was like, “Oh, that must mean you're feeling better. Well then, we don't have to do this anymore. Lose some weight and then come back.” 16 Maru, rather than receiving appropriate screening and treatment for their cardiac concerns, found that their poor health conditions were both 1) minimized by their provider and 2) incorrectly attributed to their visible body size. As Paige, a Black queer nonbinary person, shared in a similar account, their racial identity, combined with providers’ frequent assumption that they were female, led to their experiences of physical pain being invalidated “sort of like, ‘oh, you’re just complaining.’” Paige was uneasy in healthcare spaces, where providers often made the intersections of their visible, marginalized identities salient by using them to dismiss their discomfort and, at times, deny them necessary medical attention. As Austin, a white transmasculine respondent who identified as pansexual, similarly discussed, providers frequently indicated his transgender identity as the source of his ailments, regardless of what those ailments were: I guess when I was, like, baby trans and very uncomfortable in my gender, I was very apprehensive about how other people would perceive me and how doctors would treat me. Because, anything that's wrong with me, [doctors respond as though] “Oh, it's because of the hormones. It's because of hormone replacement therapy.” Or “It's because you’re trans.” You know, like the “trans broken arm.” Austin’s mention of the “trans broken arm” refers to a phenomenon of medical misattribution in healthcare spaces in which even common conditions entirely unrelated to transgender identification—much like broken bones—are considered comorbidities exacerbated by the pre-existing “disorder” of transgender status (see Paine, 2021; Wall, Patev, & Benotsch, 2023). This experience aligned with Austin’s own as he suggested that, when he first came out as trans, his visibly queer gender expression became the primary locus by which providers appeared to assess his health concerns. Often, providers’ apparent fixation on Austin’s gender and affirming treatments obscured his presenting medical issue, thus depriving him of proper treatment. Moreover, in each of these cases, respondents reported that their providers made one or more of 17 their visible identities salient by relying on those identities to understand, evaluate, diagnose, and treat—or, more accurately, avoid treating—the patient. This routine served to misattribute individuals’ medical symptoms to their weights, and racial and gender identities, while overlooking other underlying causes for unwellness. While some respondents noted that their providers’ singular attention to their identities prevented them from accessing needed health services, others like Laria, a Native American cisgender lesbian woman, recalled how it was during the reception of their treatment that their providers communicated assumptions about them based on their visibly salient identities. Laria reflected on an experience wherein a proctologist made inappropriate comments during her colonoscopy, which she attributed to her visible Native American identity: He seemed like a very creepy guy. And when it's like, well, you know, you got to bend over to get the instruments inserted into your anus, and he's like, “Well, you should be accustomed to something like this.” And I'm like, I thought that was a really strange thing to say, because why would I be? I mean, because I'm Native American? What makes you think I've had this sort of an experience? I have not, ever. So, I mean, that was my first experience with any type of rectal exam like that. While it is not clear which particular identity or identities of Laria’s her doctor based his assumptions on, the reality likely lies in the intersection of Laria’s visible identities as a Native American woman, as she did not report her sexual orientation to her provider. In Laria’s case, as in many others, providers made assumptions based on the respondent’s visible racial and gender identities, which resulted in inappropriate comments from the provider and subsequent discomfort on the patient’s end. This was also the case for a Julian, a white gay trans man, whose gender and sexual identities became salient in an interaction with his physician wherein his doctor “spoke with [him] about concerns about having a lot of unprotected sex.” Julian expressed wry amusement with his doctor’s supposition, stating, “I thought [that] was a fun assumption. I was having unprotected sex, but with a monogamous partner.” 18 Particularly common among LGBTQ+ respondents was the experience of providers voicing assumptions regarding their patients’ sexual habits. When patients’ marginalized sexual identities became salient—oftentimes, in combination with other marginalized identity categories—the visibility of these non-normative identities subjected them to providers’ propensities to conflate sexual marginalization with sexual promiscuity. Many respondents possessing multiple marginalized identities also explained how the intersection of these identities made it difficult to predict which identities would be made salient, and potentially used as bases for discrimination, in which kinds of spaces. Riya, who identified as a Black cisgender lesbian woman, described how the interaction between her perceived masculine expression and racial identity made her nervous to enter spaces populated primarily by white women: Every time I go to the dentist, I get misgendered… I have always been a more masculine-presenting individual. I’m okay with that. But it just makes me wary to go to certain places. For example, in white spaces, if I was to go to a new doctor in [cities with a majority white population], I would be a little anxious because, if they don’t have a gender-neutral bathroom…if they have an only women’s and only men’s bathroom that maybe accommodates three or more people, I'm at risk of people thinking I am a Black man in a white bathroom. So, for me, my gender presentation as a masculine Black person, it really can be negative and scary in white spaces. Multiple respondents described similar fears about entering certain racialized and gendered spaces where they could be perceived not only as a man in a woman’s space, but specifically, as a Black man in a white woman’s space. Some individuals reported being shouted at, physically chased out of women’s spaces, and being told they “don’t belong” in places that aligned with their gender. These negative experiences were exacerbated for those whose intersecting identities made them multiply marginalized or uncertain of which identity would become the salient identifier by which others judged them at any given point in time. 19 To avoid the kinds of assumptions and discrimination that LGBTQ+ people experienced in healthcare settings, some respondents reported playing into conciliatory stereotypes associated with their identities. As Elle, a white genderqueer person, explained, when they entered healthcare encounters, they tended to draw on their perceived femininity and youth to behave “even more submissive…a little passive in a way that [they’re] not in real life.” Elle went on to reveal the internal conflict their self-presentation created. On one hand, Elle felt that the front they presented offered protection against the sort of disruptions that can occur when medical providers feel challenged. On the other hand, Elle acknowledged that their performance was not fully representative of who they were and, therefore, potentially othering to people in Elle’s community who chose not to conduct themselves deferentially. Elle added, “I try to be very like, ‘I'm non-threatening.’ I definitely can go into that, like, ‘I'm cute, don't hurt me. I'm not a scary queer person. I'm a cute trans person.’ It's just bad. I don’t love that, but I just kind of try to turn on the extra nice behavior.” Elle, aware of the mistreatment commonly experienced by LGBTQ+ individuals in healthcare spaces, anticipated the same prejudice based on their sexual and gender identities; thus, Elle attempted to avoid negative healthcare interactions of their own by assuming a sort of ambassador role that adhered to normative societal expectations of white respectability. Others who anticipated mistreatment based on their marginalized identities took a different protective approach and delayed or avoided healthcare altogether. By delaying or avoiding healthcare interactions, LGBTQ+ individuals were also able to avoid their identities becoming salient in ways that were unpredictable or driven by uncontrollable external factors, such as the assumptions providers may have made about them. 20 Healthcare Delay & Avoidance Given LGBTQ+ and BIPOC populations have a history of comparatively low healthcare utilization (see Cruz, 2014; Gates, 2014; Hsieh & Ruther, 2017; Ward et al., 2014), the circumstances under which different identities became salient in medical decision-making processes—particularly in the decision to postpone seeking health services—reflect anxieties that LGBTQ+ people have surrounding anticipated minority stressors (Brooks et al., 2022; Thomeer et al., 2018). For example, Mark, an older white cisgender gay man in an interracial relationship, commented on how his visible race, age, and sexuality, paired with those of his partner, became salient in his decision-making process in ways that contributed to the couple’s delayal of healthcare: I like to make appointments for me and my partner. We like to do these things together. So, I'm kind of worried about making that appointment and wondering what they're going to think. Not because of the gay thing, but because of the Black and white thing. Because, I mentioned my partner is Black. He's sixteen years younger than I am, so there's a lot to talk about there, as far as a dentist or maybe even a doctor. I've kind of been putting it off, that card has been sitting there for a couple of months. Mark reported “putting off” dentist and doctor visits because he was uncertain which spaces would welcome him and his husband given the combination of their salient, visible identities. By avoiding healthcare interactions altogether, Mark was able to avoid potential discrimination based on his and his partner’s visibly salient racial identities, as well as uncomfortable moments in interaction during which providers might have challenged Mark’s personally salient role-identities. Healthcare avoidance was also frequently cited in situations where patient identities were misaligned with provider identities, resulting in the discontinuation of necessary healthcare services. This was the case for Rhoda, a white Latina cisgender pansexual woman, whose race 21 became relevant to her mental health following the rise of the sociopolitical landscape influenced by the 2016 presidential election, and then salient during her interactions with a Black therapist: Initially I was seeking out [therapy] because, over the last several years especially, we've had a lot of racial turmoil in this country, and so, it's caused a lot of feelings within myself about my own experiences and who I am. And I really needed to talk to someone. I looked and looked and looked for either a mixed or Latina therapist. And the one that I found was not accepting patients, bummer. And so, I went with a recommendation of a friend to go see this Black [woman]. And she was very helpful, very kind. As you said, we had a good rapport. But at the end of the day, I actually felt really uncomfortable, because I didn't feel that it was appropriate for me as a person of mixed white and Latina heritage to be burdening a Black woman. You know, we are both racial minorities. It's just, with everything that's going on, it just didn't feel appropriate. Even though she's a therapist, even though this is her profession, this is what she does for a living, it did not feel appropriate for me…even to be telling this Black person how mixed up I felt and how much inner turmoil I felt. Because undoubtedly, she is experiencing probably worse turmoil. You know? Because I know that I'm white presenting. And so, you know, her experiences as an inescapably Black woman have been much harder. It felt incredibly inappropriate for me. And so that was why I kind of tried it for a little while and then I ended up just ending my time with her because I was just like, this is not the right fit for me. Rhoda expressed how her visible whiteness did not fully communicate her invisible identity as a mixed person of white and Mexican descent. Both Rhoda’s visible and invisible racial categories made her feel uncomfortable discussing racial issues with her therapist, given her therapist’s own visibly marginalized identity status. In not wanting to burden an individual assumed to experience harsher racial discrimination and colorism, Rhoda opted to discontinue her much-desired mental health services. Similarly, Rachel, a white cisgender lesbian woman, described how her visible body size and invisible sexuality discouraged her from receiving adequate mental healthcare when interacting with a doctor who she identified as possessing similar identities: I was afraid of my weight now, and I was afraid that I was gay. So, I went to this other [therapist]. And so, I went there, I went to one session. The man that was there was very flamboyant and very overweight or obese. And my thought process was, “I’m going to offend this man, and I don’t want to offend him.” So, I couldn’t tell him how I felt. I finished up my 22 session with him, and I never went back. And so, I had to try to deal with this for another couple years until I was just able to do it on my own. Rachel, who at the time was struggling with body image issues and shame surrounding her sexuality, stated that she discontinued her mental healthcare due to the fear of insulting a provider who she determined to share similar salient identities. In prioritizing her provider’s wellbeing over her own, Rachel admitted to not receiving the necessary care and acceptance she might have benefitted from otherwise. Patients Educating Providers A spillover consequence of LGBTQ+ individuals feeling misunderstood by their providers was that, when they made it into the doctor’s office, they spent a great deal of time educating providers about their identities. Bili, for example, who identified as a white transmasculine genderqueer person, described an instance wherein their anxiety surrounding a long-distance relationship led to their queer identities becoming salient—and subsequently misunderstood—during a mental healthcare session: I was like, “This person is confused by queer life and my gender.” Not that we got that deep into it, because the therapist didn’t really know much. And I think what I found frustrating was…[providers] will say they're LGBT-affirming, or knowledgeable, and they just really aren't. And so, you end up spending time kind of educating them…So yeah, I ended up not having a great experience with that person. For Bili, as for many others, the necessity of educating their healthcare provider about their sexual and gender identities detracted from their designated treatment time and resulted in negative healthcare experiences. As a result, respondents reported feeling discouraged and disillusioned by the healthcare system, particularly in cases where providers advertised themselves as possessing expertise in LGBTQ+ health issues. Lan, a white and American Indian polyamorous person, explained how their otherwise invisible sexuality was made salient during a mental healthcare encounter in which their therapist 23 stigmatized their relationship composition, which was not the focal point of their session. Lan shared how it became their responsibility to inform their provider about their misconceptions, stating: I've just had to explain because therapists immediately, in the past, they've been like, “It’s a warning sign that you’re cheating on your partner.” I’ve had to be like, “Okay, let me get my Poly 101 presentation out. Everybody knows about everything. Everybody's consenting. Everybody talks about things. Et cetera. It's not cheating. Everyone’s cool with it.” Or they see it as some kind of thing like, “Oh you can't settle on someone, so you have some kind of attachment issue. Et cetera.” Or things like that. Or they think that it’s a risk behavior. I’m like, I don't have time to have sex with a million people. I'm scheduling dates [laughs], trying to fit everyone into my schedule to hang out, to be honest. Most polyamory is scheduling, to be honest. And, I don't know, it just feels like they make judgments about it a lot, unless I have the time to explain. In casually discussing an important and inseparable aspect of their life (i.e. their romantic relationships), Lan faced critiques that patients in monogamous heteronormative relationships likely would not. These stigmatizing perceptions of Lan’s relationship produced a negative healthcare experience, as Lan felt obligated to dedicate their allotted appointment time to educating their provider instead. Lan continued to express that, while they accepted that everyone is at their own point in their learning journey, and while they worked to remain graceful through instances of misgendering and obligatory educating of providers, there was a great emotional burden that came with continually helping the professionals whose job it was to help them. LGBTQ+ individuals were expected to move freely between the boundaries of “patient” and “teacher.” This often proved frustrating for LGBTQ+ patients, who were not formally qualified to train their healthcare professionals on diversity and inclusion initiatives nor compensated for their distribution of knowledge. While feeling compelled to educate providers often took an emotional and physical toll on LGBTQ+ people—particularly when their expertise was demanded or dismissed—many took favorably to providers who appeared open-minded, 24 receptive to new knowledge, and willing to take initiative to learn more on their own. Mae, a Black nonbinary lesbian, shared a positive example of the power of patient-provider education, saying: The doctor was really nice…It was kind of like she helped me. I had to get a pap smear, and I hate pap smears. So, we did that procedure and she was very gentle…Then, I told her that I'm a lesbian and that I was sexually active. I asked what the best forms of [STI preventions] were, because I know what they are but I just was wondering, from her perspective, if she knew of anything better. So, I told her about dental dams. She didn't know what a dental dam was. To me that was not necessarily a red flag, but it just seemed like she was used to seeing a lot of cisgender, heterosexual patients talking about heterosexual sex and she hadn’t really dealt with lesbian sex before. Overall, LGBTQ+ respondents reported less negative healthcare experiences when they felt that their identities could be made medically salient on their own terms, and when their providers were willing to actively learn and incorporate salient identities into their healthcare interactions without requiring free educational labor from patients. When Identity Salience Misaligns In many instances, respondents reported that the interactions between their various social identities resulted in some identities being prioritized over others within healthcare settings, which unsettled distinctions between identity salience and identity in/visibility. Addy, a white cisgender lesbian woman, described how, in the context of her largely populated and diverse city, her visible middle-class whiteness became more salient in healthcare encounters than her marginalized sexuality and gender expression, thus protecting her from sexual- and gender-based discrimination in ways that LGBTQ+ people of color may not experience. According to Addy: My insurance card gives me some privileges that a lot of other people don't have…That is a thing that I've noticed helps me: my white privilege…when people see me, and see my name on paper, and then see my picture, a lot of assumptions are made. I wear a lot of…collared shirts and bow ties or neckties. I'm perceived as someone who has money and is well off. I don't consider myself that. That tie cost four dollars, but that’s not the point. I am perceived that way. There are enough people in the area that my perceived sexuality is not a problem. 25 So, that thing that would [otherwise] cause an issue is gone. So, all they see is my whiteness and my professionalism. I'm a white-collar worker…My whiteness trumps so many other things, which is shocking to me, but it does. People see that I'm white before they see I’m butch or masc. It's a close second, but it's second. Addy expressed discomfort with how salient her racial identity became in healthcare spaces when compared to her other preferred expressions of self. At the same time, Addy acknowledged the privileges afforded to her because of her perceived middle-class whiteness. In other instances, participants suggested that providers treated them well in regard to their visible race; however, when their sexuality became salient upon inviting a same-gender partner into the doctor’s office, the interactions shifted. As Tara, a Black cisgender lesbian woman, noted: We found [a female doctor] and she seemed to listen. That was when I first went in. Then, it became a little more tense when my partner started visiting. When I went alone, it was just little Black [me] so I’ll see her and it’s okay. But when I came with someone else who was also female, it became a little tense in the office community. At the start of Tara’s healthcare interaction, her visible race and gender were determined to be the most salient identifiers by which providers judged her. Then, upon introducing a same-gender partner into the healthcare space, Tara’s invisible sexuality became salient and altered her doctors’ behaviors that were initially informed by her visible race and gender. While Tara’s invisible sexuality was made visible in her healthcare encounter, respondents more often perceived that providers tended to neglect their less visible identities, leaving patients wondering which identities they should “lead with” in medical spaces. As a result, many respondents shared that they had to “compartmentalize or fragment” themselves. According to Aria, a white and Native American cisgender lesbian woman, “the way gender is seen and sexuality is seen is that it’s so black and white…and the assumptions about race or anything like that, it erases pieces of you.” Respondents like Aria, who held multiple racial and 26 cultural identities, expressed that there were rarely opportunities to relay these intersecting identities on medical intake forms; instead, respondents were required to “just pick one” of the limited options available, which may or may not include any of the individual’s true identity categories. At times, providers used visual cues to draw conclusions about patients’ presumed racial identities. This method of racial identification proved inadequate, as an emphasis on skintone frequently dismissed individuals’ racial identities. Shan, a Native American cisgender lesbian woman, recalled how her provider marked her race as “Caucasian” on her medical forms based on her visual appearance. When she requested that her recorded race category be changed to align with her true racial identity, the provider was reluctant to correct the error: She kind of looked at it for a minute and looked at me. I said, “No, this needs to say ‘Native American.’” And she kind of looked at the form and looked at me again, and then changed it… It didn't appear as if she were happy about it, but she did it. I mean, I know they had to go back into the form and change it and reprint it, but okay, so what? You have to have it right. Shan explained that this interaction made her feel as though her racial identity were being erased simply because she had not inherited many of the physical attributes the rest of her family had, or traits stereotypically associated with Native Americans in popular media. In reflecting on the contextual nature of identity salience, Shan went on to describe a contradictory experience in which an urgent care nurse commented that she was “surprised to see [Shan] marked ‘white’ on paperwork.” According to Shan, “It cut both ways, and both times, it was surprising. It always catches me off guard. It just depends on who I’m talking to and what the issue is.” Shan’s experience of having her Native American identity erased or emphasized, depending on the provider with whom she was interacting, resulted in feelings of fragmentation and invisibility across healthcare spaces. Such responses were common among individuals whose race became salient in medical contexts after they either had no space to accurately 27 indicate their racial identities, or because their racial identities were incorrectly ascribed to them by providers. Relatedly, respondents described instances wherein their sexual identities were made salient either through over-emphasis or erasure in healthcare settings. Chrisy, who identified as a Hispanic cisgender lesbian woman, shared that it felt frustrating to have her sexual identity become salient in healthcare spaces solely due to providers’ minimization of her romantic relationship. She described an instance in which her wife’s provider continually referred to her as a “friend,” despite being corrected, stating: My girlfriend at the time was in the hospital and, you know, the doctors come in there, introduce themselves, and they'll ignore you. [Doctors say] “Okay, your friend” and [my partner]’s like, “No. That’s my girlfriend.” Actually, no, I think we were married at that point and she said, “That's my wife,” [but the doctors just kept saying], “That's your friend.” It always kept being reduced. “That’s your friend.” And it was one of the older doctors, so it still feels a little difficult. The nurse was better. …It kind of aggravates you because you feel like they’re not taking you seriously, and it aggravates you because, if it were a straight couple, they wouldn’t be doing that. They shouldn't be treating us any differently than they would a straight couple that came in.” According to Chrisy, part of her frustration lay in the fact that, had she been involved in a heterosexual relationship, her sexual identity would not have become salient in such a way that her providers would feel the need to respond to their own discomfort by dismissing her relationship to her married partner. The fragmentation of patient identities illustrated in our data is concerning when we consider research that demonstrates how more social roles are associated with increased beneficial individual resources like social connections, power, and prestige (Ahrens & Ryff, 2006); lower levels of psychological distress (Kikuzawa, 2006; Sachs-Ericcson & Ciarlo, 2000; Wethington et al., 2000); and fewer physical health problems (Barnett & Hyde, 2001; Janzen & Muhajarine, 2003). As such, those individuals with more identity avenues through which to 28 obtain beneficial resources report better health outcomes; conversely, having identities erased via provider-determined salience contributes to poor outcomes related to constrained resources. Taken together, it becomes clear that, to begin combatting medical inequity, we must first create spaces for LGBTQ+ patients to provide accurate, holistic information on the interactions between their intersecting identities and their health behaviors and outcomes. Inclusion and acceptance of diverse experiences in healthcare would yield more accurate data regarding health disparities across a wider range of identities that exist in the real world and which have concrete consequences for minority health. 29 CONCLUSION I demonstrated how LGBTQ+ individuals must constantly negotiate the expressions of their various intersecting identities within healthcare spaces, particularly as they relate to provider identities and presumptions. Despite LGBTQ+ patients’ active processes of identity negotiation, healthcare providers were perceived by respondents as 1) using visual identifiers to determine patient identity salience, and then, 2) drawing conclusions about LGBTQ+ patients based on dominant cultural narratives surrounding these visual identities. However, the reduction of salient identities into those which were clearly visible to providers proved inadequate in determining patients’ self-claimed salient identities. As a consequence, providers often incorrectly ascribed social identities to their patients based on appearance, thus contributing to patients feeling that providers had neglected their less visible identities while prioritizing a selective set of provider-assigned identities, regardless of their personal relevance to the patient or their health. When they did happen to come up during healthcare interactions, participants also described providers making prejudicial assumptions about their less visible salient identities. The necessity of salient identity negotiation in healthcare spaces was particularly prevalent among LGBTQ+ people of color and other participants holding multiple marginalized identities, as they felt the need to choose which identities to “lead with” in attempts to avoid the experiences of healthcare discrimination that disproportionately impact LGBTQ+ populations. Because different identities became salient in different healthcare contexts, respondents reported how the salience of some identities tended to erase other aspects of themselves, depending on the situation. Often, providers’ perceived prioritization of singular patient identities produced two major consequences: 1) LGBTQ+ individuals were made uncomfortable when their identities—both visible and invisible—achieved other-perceived salience in ways that 30 felt irrelevant, stereotypical, or counter-productive to the healthcare encounter, and 2) LGBTQ+ individuals felt troubled when their less visible, but personally-salient identities were obscured or erased during healthcare interactions. Perhaps the most significant limitation of this study is that, while our sampling method sought to highlight the often overlooked healthcare experiences of BIPOC LGBTQ+ people, some gender demographics remained underrepresented. As such, while the present data speak strongly to the experiences of nonbinary, genderqueer, and cisgender individuals who identify as LGB, future health research should prioritize capturing the experiences of binary transgender people, as their experiences may be qualitatively different than those of cisgender LGB individuals. A further limitation of this study is that, given only patients—and not providers—were interviewed, it is not possible to parse which explicit contexts produce which forms of identity salience among LGBTQ+ patients. Emerging health research should seek to engage with healthcare provider perspectives. Future studies would also benefit from centering on interactions between patient and provider identities (see Owens et al., 2010, p. 488, for a discussion of how an individual’s perception of groups they do not belong to becomes “outgroup stereotypical” as opposed to “ingroup normative”). At the same time, patient perspectives are invaluable in examining LGBTQ+ people’s interactions within, and responses to, healthcare encounters. Allowing space for patient perspectives also offered researchers a way to gauge best practices in LGBTQ+ healthcare, moving forward. Overwhelmingly, when reflecting on what contributed to positive healthcare experiences for LGBTQ+ patients, respondents suggested that it would be most helpful for providers to casually acknowledge people’s self-reported identities, rather than making assumptions, and then 31 to offer space to allow the patient to determine if and when those self-reported identities should become the salient focus of their healthcare encounter. As Mickey, a white nonbinary pansexual person who expressed how much more satisfying their healthcare interactions became when providers were just willing to listen, respect their identities, and provide the same high quality of care that they would give to anyone else, noted: The biggest thing…has been when I do run into someone who makes space for me and who I am, but not as an event. It's not, “Oh, we've got a non-binary person coming through.” No, I don't need special treatment. I just want to know that if my pronouns are made clear, that they’re going to be respected, and it's not going to cause an issue… At that point where you encounter someone who's respectful casually, things just speed right up. They get easier, I feel like I can breathe more. It's night and day. And so if we didn't have to go looking for those people, it would be amazing. Every intake person should understand and respect pronouns everywhere. If they did, that would make all trans people, all queer people more likely to even seek out assistance.” According to Mickey, healthcare interactions produced the most positive results for queer patients when providers were able to incorporate sexual and gender minority identities into their healthcare encounters in ways that normalized them, as opposed to attracting undue attention and stigma. Moreover, as Austin shared, identity salience could prove useful in determining treatment options for queer folks: All I want is just basic healthcare. I just want people to be like, “Oh, you’re trans. Are there specific healthcare needs that you feel we need to address?” That’s all I want to be asked… I just want to be treated with a certain level of dignity and respect. I don’t need to be coddled or held in any way. I just want to go in, and the doctor’s like, “I see on here that you’re a transgender man. 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