Six months into the COVID-19 vaccination rollout in the U.S.— and President Biden’s plan to have 70% of Americans at least partially vaccinated by July 4—we’re continuing to see that when it comes to coaxing a change of heart in unvaccinated Americans, both the message and the messenger are important—and those depend heavily on which group is being urged. Political leaning is one factor, with 43% of Republicans saying they will not get vaccinated, a sentiment reportedly connected to a distrust of government and science.
Gender factors in, too: Men are more likely to flatly refuse a shot than women. Those with less education are also more likely to either reject vaccination or take a wait-and-see approach. As for messengers, Americans across the board are less likely to listen to public health organizations, with only the Centers for Disease Control and Prevention (CDC) scoring above 50% in trustworthiness—and more inclined to listen to doctors, nurses, and other health care workers.
Addressing Vaccine Barriers in the LGBTQ+ Community
Recognizing there are overlaps among all these groups, health officials have to craft a variety of messages—and find trusted messengers—that resonate with the most people and turn off the least amount of people. Of note, the message of “We’re all in this together, so do your part and get vaxxed,” is extremely unlikely to motivate Trump Republicans, according to one GOP pollster.
Men who have sex with men (MSM) and LGBTQ+ identifying Americans have been left out of nationwide surveys, at least by the federal government, but one nationwide survey revealed some disturbing data about the willingness of LGBTQ+ Americans to get vaccinated. With a caveat that the data were collected early in the vaccination cycle, a recent analysis from the Human Rights Campaign Foundation and PSB Insights showed that only 42% of LGBTQ+ Americans were very likely to get vaccinated for COVID-19. Of bisexual adults and bisexual women, 38% and 32%, respectively, said they were very likely to get vaccinated. Black LGBTQ+ adults were even less likely to get a vaccine—less than a third (29%) said they were very likely. The reasons ranged from concerns about side effects to expected costs of obtaining the vaccine.
A handful of smaller, regional surveys of LGBTQ and MSM vax attitudes offer more encouraging news and helpful strategies. Even so, members of this community who have not been vaccinated face barriers to getting vaxxed, which map onto barriers to health care overall.
Pennsylvania’s Trusted Messenger Was Helpful
A statewide survey of LGBTQ+ Pennsylvanians, conducted by the Bradbury-Sullivan LGBT Community Center in Allentown, Pennsylvania, and Bryn Mawr College, questioned 1,545 LGBTQ Pennsylvanians from 56 out of 67 counties and across 413 zip codes between March 4 and April 5, 2021. The survey revealed that the majority of respondents had received at least one dose of a COVID-19 vaccine. Of those who had not received a dose, more than 85% said they would get a vaccine as soon as they could. However, there were notable barriers: Just over 40% of those not yet vaccinated said they did not know where to get the vaccine, and 46% had not yet contacted anyone about making a vaccine appointment. Of LGBTQ Pennsylvanians who were either undecided or unwilling to get the vaccine, 58.7% were concerned about vaccine safety and 35.9% about vaccine effectiveness.
Of Pennsylvanians who reported being hesitant or unwilling to get their shots, 38% said they wanted to make sure others were vaccinated before they were, a finding Adrian Shanker, the executive director of the Bradbury-Sullivan Center, found surprising.
“There was a feeling that others need the vaccine more than they do,” Shanker said. He added that such feelings may dissipate now that vaccines are widely available for adults and teens. A more difficult problem for LGBTQ+ health advocates, Shanker added, is addressing the fear of not being treated equitably, which is an issue for accessing health care generally. “Trans people and non-binary people want to make sure they won’t be misgendered by health workers,” Shanker said.
That awareness and fear of discrimination are borne out by past and recent studies. A 2015 survey from the National Center for Transgender Equality revealed that one-third of transgender people had either been turned away by a doctor or health provider or experienced discrimination and harassment while seeking medical care within the past year. Almost a quarter said they had put off going to the doctor in fear of mistreatment.
For transgender Pennsylvanians, though, there has been a trusted messenger, at least where COVID-19 is concerned. The state’s top health official last year, before she was chosen to be the U.S. assistant secretary of health, was Rachel Levine, M.D., a trans woman. “Dr. Levine was on TV every day for a year, and it didn’t matter what Trump said,” Shanker said. “It made a difference.”
As for what health officials and advocates can do to decrease barriers, including the attitude barriers, for LGBTQ+ people, Shanker strongly recommended community-based vaccine clinics run by LGBTQ+ people, for LGBTQ+ people. Since mid-March, Bradbury-Sullivan has offered LGBTQ COVID-19 vaccine clinics and has arranged over 1,000 doses through clinics held on-site. And the Center was just tapped to provide technical assistance to five other LGBTQ+ centers in the northeast mid-Atlantic, with a grant from the Leonard-Litz Foundation, to bring in even more people for COVID-19 vaccinations.
A Positive Shift in Boulder
A survey conducted by research psychologist Kaylin Gray, Ph.D., for Out Boulder County (OBC), in Colorado, showed that, before vaccines were available in the community, the LGBTQ+ vaccine hesitancy rate was higher than the non-LGBTQ rate—17% versus 9%—though still lower than the hesitancy or resistance rate for other groups nationally. A soon-to-be-released follow-up survey of compiled data several months into the vaccination effort showed a positive shift: The vast majority of the 297 respondents had already been vaccinated and, of those who had not been vaccinated, only five people indicated vaccine hesitancy.
What moved the needle? According to Gray and OBC’s executive director, Mardi Moore, three actions had a big impact: a well-attended and widely publicized town hall with local doctors explaining the safety and effectiveness of the vaccines, with LGBTQ+ concerns in mind; a dedicated vaccine resource page; and a media campaign addressing vaccine hesitancy.
OBC has also advocated for sexual orientation and gender identity (SOGI) data to be collected by public health officials on COVID-19 vaccination intake forms, which the state now collects. OBC is also partnering with three other Colorado LGBTQ+ centers to provide local data and grant funding for vaccine equity clinics in their counties.
Moore echoed the vaccine insights of other LGBTQ+ advocates. “You can’t shake your finger and say, ‘Get vaxxed,’” she said. “It doesn’t work to cajole.” Although Moore said she’s heard some in the community parroting conspiracy theories about the vaccines, it’s best not to address those misconceptions at all. “It’s better to talk facts.”
Despite their success in lowering vaccine hesitancy, OBC found some concerning statistics about LGBTQ health access in general. “There are barriers of concern over money and transportation and copays,” Gray said. “Our data show that 43% (of LGBTQ+ people) didn’t have a trusted doctor.” The same percent said they are more comfortable going to an LGBTQ+ clinic for health care.
Come for the Vaccine, Stay for the Health Care
Other health officials continue to swear by the trusted messenger—and trusted institution—strategy, including Philip Chan, M.D., chief medical officer of Open Door Health and consultant medical director at the Rhode Island Department of Health. Chan, who led the state’s COVID-19 response, said those messengers could be LGBTQ+ champions—even better if they’re also doctors or nurses—and that vax sites that cater to the community are more likely to be trusted.
“There have been pockets of hesitancy but generally good [vaccine] uptake in Rhode Island,” Chan said. “We set up pop-up clinics, we are getting into the communities. That’s one reason Rhode Island has one of the highest vaccination rates.” He added that public health organizations could probably do more to lower the barriers to access, though, including streamlining online systems and making them friendlier and easier to use.
Chan said that health officials would also do well to use vaccination sites as an opportunity to engage, or re-engage, LGBTQ+ people in other aspects of health care. “One bad thing about the pandemic is, a lot of primary care has been deferred,” he said. “The CDC doesn’t recommend administering other vaccines within two weeks [of the COVID vaccine], but we have been encouraging other health screenings for STDs and HIV, for example, and using the COVID vaccine as a chance to encourage people to get into care.”
In a panel discussion last month sponsored by Open Door Health, several health practitioners agreed that with the COVID-19 vaccine, if you can get people vaxxed, you may also be able to encourage them to consider other preventative health measures.
“With hep B and HPV—even pertussis patients don’t remember those vaccines exist, at least not until there’s a life event and they need a pertussis booster,” said Will Giordano-Perez, M.D., AAHIVS, a family medicine physician at Tri-County Health Clinic in Providence, Rhode Island. “We can say, ‘While we’re [giving the COVID vaccine], have you gotten the hep B vax yet?’ For some folks, it isn’t on the radar because we don’t advertise it.”
In the same webinar, Tim Cavanaugh, M.D., a family medicine physician in Cranston, Rhode Island, specializing in LGBTQ health issues, said a COVID vaccination is a good opportunity to recommend the vaccine for human papillomavirus (HPV), which is important because MSMs are at a higher risk of anal cancer, often caused by certain strains of HPV. The HPV vaccine is approved for use in individuals up to age to 26 (some 27- to 45-year-olds may get the HPV vaccine after talking with their doctor, but whether insurance will cover it is another matter). The theory behind the age restriction is that sexually active people over 26 have likely been exposed to at least one strain of HPV, and therefore the protection offered by the vaccine would come too late. Still, Cavanaugh recommends the HPV vaccine, even if someone may have been infected—and there’s no antibody screening test for men to tell if they’ve been infected—and adds that MSMs should also consider getting vaccinated for hepatitis A and B, because they are at higher risk of contracting these viruses.
What About Incentives?
None of the LGBTQ+ centers and clinics contacted by TheBody said they used financial incentives to bring in more people to get COVID-19 vaccinations. But that doesn’t mean they couldn’t be effective. For the larger population, cash works. In Ohio, the chance to win a million dollars for being vaccinated sparked a 28% increase in vaccinations in recent weeks, according to Gov. Mike DeWine.
With the feds giving thumbs up to financial incentives, several other states opened lotteries and other cash prizes for vaccinations. Some states and cities are offering scholarships, season sports passes, fishing licenses, and park tickets. For an LGBTQ+ population and clinics and community centers on a limited budget, there may be cost-effective ways to get more people to roll up their sleeves and get the jab.