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LGBTQIA+ Quality of Life Study City Council Presentation October 2021 1 Copyright © 2021 Health Management Associates, Inc. All rights reserved. 1 HMA Community Strategies Research Team 2 2 • Charles Robbins, MBA • Iliana Gilman, MA • Michelle Parra, PhD • Catherine Guerrero, MPH • Ryan Maganini Copyright © 2021 Health Management Associates, Inc. 2 City of Austin’s Equity Office 3 3 • Brion Oaks, Chief Equity Officer • Kellee Coleman, Business Process Consultant, Sr. • Amanda Jasso, Equity & Inclusion Program Manager • Rocío Villalobos, Immigrant Affairs Program Manager • Joshua Robinson, Equity & Inclusion Program Coordinator • Enakshi Ganguly, Public Information Specialist, Sr. • Brandon Kroos, Business Process Specialist Copyright © 2021 Health Management Associates, Inc. 3 LGBTQ Quality of Life Advisory Commission 4 4 • Ruben Baeza • Sandra Chavez • Charles Curry • Kannou Curette • Tarik Daniels • Deirdre Doughty • Nan Dowling • Saul Gonzalez • Christina Gorczynski • Kathryn Gonzales • Terrance Hines • Holly Kirby • Rebecca Dreke • Dr. Victor Martinez • Melissa Taylor • Brandon Wollerson • Tarik Daniels Copyright © 2021 Health Management Associates, Inc. 4 Community Partners Copyright © 2021 Health Management Associates, Inc. 5 Community-based Research Advisory Board • Provide feedback and guidance throughout the project • Application process was widely promoted • Received 35 applications – 11 finalists were chosen (73% POC) • Met four times at key stages during project • $1,000 stipend for their participation ($250 per meeting) Sexual Orientation of Research Advisory Board Members Sexually Fluid 9% Queer Pansexual Lesbian Heterosexual Gay Asexual 18% 9% 9% 9% 36% 73% 0% 20% 40% 60% 80% *Note: Disclosing demographic information was optional and some board members reported multiple categories for a given identity; percentages do not total to 100%. Copyright © 2021 Health Management Associates, Inc. 6 Research Advisory Board ALEXANDER ANDERSON (he/him) KB (they/them) RICHARD BONDI (he/him) SHA’NYIA BALTIMORE (she/her) SAM DAVIS (they/them) TABITHA HAMILTON (they/them) LEX KEATON (they/them) ROCKY LANE (he/him) LAIS MILBURN (she/her) PHILIP SCHNARRS (he/him) ALEXANDER ZAPATA (he/him/they/their) Copyright © 2021 Health Management Associates, Inc. 7 Background • No previous official city-wide data collection effort to understand the LGBTQIA+ community • Official demographic data definitions do not typically account for sexual orientation and gender identity (SOGI) • The twin public health emergencies underscored the fundamental need to reconceptualize the meaning of community and quality of life • Of significant note, people of color represented 43% of individuals who completed the survey during a time of growing mistrust of government institutions Copyright © 2021 Health Management Associates, Inc. 8 Context • Study was centered in equity • Highlights traditionally underrepresented populations often unaccounted for in demographic data collection efforts (e.g., queer and transgender people of color, gender expansive individuals, LGBTQIA+ youth, and older adults) • Conducted during a pandemic and racial unrest, presenting many challenges Copyright © 2021 Health Management Associates, Inc. 9 LGBT Population in US, Texas, and Austin • The Williams Institute estimates 4.5% of the total US population is LGBT (July 2020)1. • 4.1% of the total population is estimated to be LGBT in Texas • March 2021 study, the Austin-Round Rock-Georgetown metropolitan has a higher density of LGBT people, estimated at 90,000 (5.9%) • Metro Austin is home to the 3rd largest percentage of LGBT people in the country (behind Bay Area and Portland). • With a total population of almost 2.3 million in Greater Austin – between 100,000 - 118,000 are LGBT. 1. Conron, K.J., Goldberg, S.K., Adult LGBT Population in the United States. (July 2020). The Williams Institute, UCLA, Los Angeles, CA Copyright © 2021 Health Management Associates, Inc. 10 LGBT Population in US, Texas, and Austin Williams Institute, March 2021 Copyright © 2021 Health Management Associates, Inc. 11 Austin has a Rich History of LGBT Activism • 2019 Austin Chronicle article entitled The History of the LGBTQ Movement In Austin: From Stonewall to today, how Pride has progressed in our City • Serves as an overview of the prolific history of the LGBTQIA+ community in Austin Copyright © 2021 Health Management Associates, Inc. 12 Definition of QoL for LGBTQIA+ People • Quality of life is the general well- being of individuals and societies, outlining negative and positive features of life. • It consists of the expectations of an individual or society for a good life. • These expectations are guided by the values, goals and socio-cultural context in which we live. Copyright © 2021 Health Management Associates, Inc. 13 Methodology • Adapted a Quality of Life framework developed by Habitat for Humanity • Identified 7 outcome domains through community input • Utilized a mixed-methods, community-based participatory approach • Qualitative data: • 30 key stakeholder interviews • 2 virtual community town halls (152 participants) • 4 focus groups – African American, Asian American, Older Adults, Transgender and Gender Expansive individuals (38 participants) • A Power Analysis of each outcome sector • Quantitative data: • 156-question online survey (available in print and threshold languages) • 2,149 completed responses • Represents 89 zip codes in Travis, Hays, Bastrop, Williamson, Burnet, and Blanco counties Copyright © 2021 Health Management Associates, Inc. 14 Quality of Life Outcome Sectors QUALITY OF LIFE COMMUNITY AND SOCIAL CONNECTEDNESS ECONOMIC OPPORTUNITY AND WORK EDUCATIONAL OPPORTUNITY AND ACCESS HEALTH HOUSING PERSONAL SAFETY SOCIAL AND PUBLIC SERVICES/BENEFITS Copyright © 2021 Health Management Associates, Inc. 15 Copyright © 2021 Health Management Associates, Inc. 16 Community Stakeholder Engagement KEY STAKEHOLDER INTERVIEWS TOWN HALLS AND FOCUS GROUPS CONSTITUENT SURVEY Iterative feedback provided by: Research Advisory Board, Community Partners, LGBTQ Commission, Equity Office Copyright © 2021 Health Management Associates, Inc. 17 Key Stakeholder Interviews (30 people) Copyright © 2021 Health Management Associates, Inc. 18 Key Stakeholder Interviews (30 people) Copyright © 2021 Health Management Associates, Inc. 19 Community Survey (2,149 people) Copyright © 2021 Health Management Associates, Inc. 20 Community Survey (2,149 people) 43% people of color Amnesty International estimates that 1.7% of the world population is intersex. Planned Parenthood estimates that 1-2 people in 100 in the U.S. are intersex. Copyright © 2021 Health Management Associates, Inc. 21 Key Themes Greater Austin is home to a large (est. 100,000 – 118,000) and vibrant LGBTQIA+ community with many influential organizations and activities. • Austin has a rich history of queer community life and activism, including its first documented gay bar – The Manhattan Club – which opened in 1958 and the formation of the Austin Lesbian Organization in the 1970s. It’s important to note that bars have historically been the primary place where LGBTQIA+ people socialize. • There is a high degree of acceptance by chosen family and friends (83%), with biological family (55%), and at work (51%). • Two-thirds of survey respondents indicate a high satisfaction of overall quality of life (66%), and three-quarters feel their life is meaningful (77%). • Qualitative data affirms community resiliency and a capacity for creating a participatory, intersectional LGBTQIA+ community. • There is a great desire and need for a community center led by community members that provides a safe space for people to convene with their chosen family. Copyright © 2021 Health Management Associates, Inc. 22 Key Themes Societal stressors, structural racism, and discrimination impact the quality of life for LGBTQIA+ individuals in Austin. • There are confounding effects of multiple oppressions. • 50% reported a diagnosis of neurodivergence (anxiety, depression, PTSD, ADHD) • Qualitative data suggests increased living and housing costs, gentrification, and poor public transportation impact QoL and drive racial and ethnic disparities. • 4 of 5 respondents believe racism is a public health crisis (83%). • Respondents reported discrimination based on race, orientation, and identity. • Half (52%) knew someone in Austin who experienced a physical threat or attack and half (53%) reported experiencing verbal abuse or harassment in Austin because they are LGBTQIA+. Copyright © 2021 Health Management Associates, Inc. 23 Key Themes It is challenging for LGBTQIA+ organizations to bridge racial and socio-economic divides within the LGBTQIA+ community. • Stakeholders pointed to a need to address racism within and outside the queer community with more thought and attention and noted that racism exists within the LGBTQIA+ community (not always “us” vs. “them”). • Stakeholders find identity with their community, yet it remains fragmented, and that creating a connected community requires venues that allow for mixed and identity-specific spaces to reflect all races, ethnicities, ages, identities, and orientations. • Power Analysis highlights the need to lift and invest in smaller and less influential organizations whose agendas support the LGBTQIA+ - many provide services exclusively on behalf of queer PoC. • A significant number of participants expressed a need for more intentional engagement of queer PoC and transgender individuals in community building and organizing. Copyright © 2021 Health Management Associates, Inc. 24 Key Themes There is a need for high-quality, affordable, culturally responsive, integrated health care. • Most respondents (63%) reported worrying about their health. • Study participants do not believe most health care providers have the medical expertise and cultural competency to address their unique health needs as LGBTQIA+ people. This is especially true for transgender and gender-expansive individuals as there is a need for more gender-affirming providers. • Although 63% of respondents indicated they didn’t choose their primary care provider based on their knowledge of the health care needs of LGBTQIA+ people, a significant number (37%) said they make this choice based on the provider's knowledge. More surprisingly, 41% of respondents did not share their LGBTQIA+ identity with their provider. Copyright © 2021 Health Management Associates, Inc. 25 Key Themes Integrated Health Care Continued • There is a great need for more health education and increased health literacy in the LGBTQIA+ community. o Eighteen percent of respondents did not receive sexual health information at school while living in o However, 21% said they received the education, but with no LGBTQIA+ information. o Surprisingly, 19% of respondents had never heard of PrEP. o While 31% of all respondents have never been tested for HIV, only 3% of respondents did not know Austin. their status. Copyright © 2021 Health Management Associates, Inc. 26 Key Themes Integrated Health Care Continued • Alcohol use is prevalent in the LGBTQIA+ community- 76% of respondents consumed a drink in the last 30 days, and 45% had consumed three or more drinks on one occasion. • Substance use is also prevalent, creating a need for harm reduction strategies. Alarmingly, of 114 respondents who indicated they injected drugs, 80% shared needles or injection equipment. • Survey respondents are at high risk for serious mental health issues, including depression (42%) and suicidal ideation (12%). Copyright © 2021 Health Management Associates, Inc. 27 Key Themes Personal safety and intimate partner violence are issues of heightened concern for the LGBTQIA+ community. • Stakeholders expressed hate is not an Austin value, yet personal safety is a concern. • Only 6% indicated a high degree of acceptance in schools. • Sexual harassment and abuse are prevalent- 57% were pressured or forced into unwanted sexual activities from someone not their partner in their lifetime, and 32% within the last 5 years. Intimate partner violence was reported by 12%. • Nearly half (48%) experienced verbal abuse or harassment from strangers. • Compared to 18%, 24% of queer PoC, 21% of youth, and 25% of transgender/gender- expansive individuals experienced negative interactions with law enforcement. • 41% are somewhat uncomfortable or very uncomfortable seeking help from police. Copyright © 2021 Health Management Associates, Inc. 28 Key Themes LGBTQIA+ community members seek affordable housing, economic stability, access to education, and equal rights. • Affordable housing and economic opportunity ranked as the most important areas of concern. Gentrification, transportation challenges, higher costs of living, and rising housing costs make it difficult for LGBTQIA+ people to thrive in Austin. • Two-thirds (65%) report spending 30% or more of their monthly income on housing, and a staggering 17% report spending 50% or more. • 10% report currently being or having experienced homelessness, slightly higher than the 2020 Williams Institute study citing 8% of transgender and 3% of cisgender and gender-expansive individuals experienced homelessness. • Over half (58%) reported some level of financial difficulty, while 11% experienced significant financial difficulties when completing this survey. Copyright © 2021 Health Management Associates, Inc. 29 Key Themes Housing, Economic Stability, Eduction, Equal Rights Continued • More than half of the survey respondents (54%) believe Austin’s residents do not have an equal opportunity to gain successful employment and high earnings. When asked whether Austin had anti-poverty programs and policies in place, almost the same number of people indicated there were (42%) as people who did not know (38%). This demonstrates an opportunity to raise community awareness about Austin’s programs and policies. • Stakeholders expressed a lack of investment in services that support physical safety and marginalized populations. There is a desire to see more support for Black and Black queer businesses from the city and mentoring and personal/professional development for Black transgender leaders to sustain community building. Focus group members expressed a need for the city to provide resources for employers to protect their employees and worker rights. Copyright © 2021 Health Management Associates, Inc. 30 Key Themes Housing, Economic Stability, Eduction, Equal Rights Continued • Thirty percent of survey respondents indicated they could not attain the level of education they wanted, and 74% indicated it was due to a lack of financial resources. • Protecting transgender and gender-expansive people from discrimination in hiring and at work was ranked as the most important policy priority for the City of Austin. Copyright © 2021 Health Management Associates, Inc. 31 Key Themes Intersectional analysis shows that disparities exist within the LGBTQIA+ population as some community members are systematically more affected by social stressors, racism, lack of safety, economic insecurity, and lack of access to needed services. These disparities are most significant among transgender people of color. • Survey respondent data indicates that queer people of color, youth, and transgender/gender-expansive individuals have greater percentages of neurodivergence, employment denials and terminations, negative interactions with police, suicidality, homelessness, income spent on housing, worry about money, reliance on public and private assistance, and dissatisfaction with quality of life. Copyright © 2021 Health Management Associates, Inc. 32 Key Themes Intersectional Analysis Continued • More strikingly, disaggregated survey data indicates transgender people of color experience the highest burden compared to youth, older adults, gender-expansive individuals, and non transgender people of color. o Transgender PoC survey respondents experience more significant employment denials/terminations, negative interactions with police, suicidality, spending more than 50% of their income on housing, and worry about money than all respondents. o Transgender PoC expressed difficulties related to housing and to finding culturally competent healthcare based on their race and identity. Copyright © 2021 Health Management Associates, Inc. 33 Overall Recommendations 1. Enhance sexual orientation and gender identity (SOGI) data collection. 2. Develop affordable housing opportunities. 3. Address health disparities and create a pipeline of culturally competent providers. 4. Lead with anti-racist policies, investments, and strategies. 5. Bolster support for queer PoC. 6. Prioritize the needs of transgender and gender-expansive individuals. 7. Invest in the establishment of an LGBTQIA+ community center. Copyright © 2021 Health Management Associates, Inc. 34 Context to Key Recommendations • Recommendations reinforce strategies of the City of Austin’s Strategic Direction 2023. Where noted, HMA ties recommendations to the City’s strategic outcomes: • Economic Opportunity & Affordability (EOA) • Mobility (M) • Safety (S) • Health and Environment (HE) • Culture & Lifelong Learning (CLL) • Government That Works for All (GTW) • Recommendations align to the City’s cross-cutting values of Equity, Affordability, Innovation, Sustainability and Resiliency, Proactive Prevention, and Community Trust and Relationships. Copyright © 2021 Health Management Associates, Inc. 35 Key Recommendations by QoL Domain Diversity, Equity, and Inclusion 1. Continue to center equity in all policy and financial resource allocations and that those allocations be inclusive of the LGBTQIA+ population 2. Continue to provide representation and visibility of people of color within city government (i.e., build workforce pipelines like paid internships, collaborations with youth camps/leadership programs, review of recruitment practices, and review of retention policies). Enforce and hold agencies accountable to the Mayor’s mandated training “Undoing Racism” 3. Collect Sexual Orientation and Gender Identity (SOGI) data across public agencies at the city and county level. Copyright © 2021 Health Management Associates, Inc. 36 Key Recommendations by QoL Domain Community and Social Connectedness 1. Investing in an LGBTQIA+ cultural center and cultural district that is inclusive of all community sectors (specifically LGBT older adults, people of color, youth and TAY and transgender/gender-expansive individuals). A community center can co-locate health and social services, event space, meetings rooms, office space, etc., and act as a clearinghouse of information for LGBT resources. 2. Empower and provide resources for the Austin LGBTQ commission to bring LGBT organizations and stakeholders together in workshops or townhalls to improve communication and advance the recommendations in this study. 3. Form a transgender/gender-expansive council through the office of the mayor. Copyright © 2021 Health Management Associates, Inc. 37 Key Recommendations by QoL Domain Economic Opportunity 1. Provide low-cost loans or grants to LGBT entrepreneurs (in collaboration with LGBT Chamber of Commerce) to start a new business, expand current operations and workforce, or buy new equipment. This requires an equitable funding model to center Queer people of color who own businesses. 2. Increase the minimum wage to a wage where LGBTQIA+ people can not only survive but thrive. 3. Enact employment non-discrimination ordinances with strong, clear penalties and robust enforcement for violations. Copyright © 2021 Health Management Associates, Inc. 38 Key Recommendations by QoL Domain Health 1. Fund transgender health care that are accessible, especially to youth. 2. Implement Project Echo on a city level to coordinate care between providers around LGBT health issues. Project ECHO is a guided-practice model that reduces health disparities in under-served and remote areas of the state, nation, and world. 3. Prioritize and provide resources for the HIV Planning Council’s 2017-21 Austin Integrated HIV Prevention and Care Plan and adopt the National Ending the HIV Epidemic strategies to reduce HIV transmission among queer and transgender PoC. 4. Develop a pipeline (internships, etc.) and establish financial incentives to attract LGBTQIA+ Asian, Black, and Hispanic healthcare providers (MD’s, MA’s, therapists). Copyright © 2021 Health Management Associates, Inc. 39 Key Recommendations by QoL Domain Housing 1. Increase awareness and access to rental assistance programs to offset housing costs. 2. Rectify the 1928 housing affordability plan with an amendment that affirms the City’s Core Values, supports and invests in developing the housing options and inventory, and protects and incentivizes Black and Hispanic-owned businesses. 3. Investigate/review all contracts to long-term use of public land. 4. Support current and long-term residents of low- and middle-income communities by investing in the building of low- and middle-income housing and divesting from luxury development in low- and middle-income areas. a. Create and enforce policies that developers cannot circumvent. 5. Enforce housing non-discrimination ordinances with stronger penalties for violations. Copyright © 2021 Health Management Associates, Inc. 40 Key Recommendations by QoL Domain Safety 1. Divestment from current policing models of safety and investing in a broader range of social response (e.g., mental health first aid, crisis hotlines for DV/IPV/Family Violence/homelessness). 2. Create a cadre of LGBT community liaisons for APD that represent LGBTQIA+ Black, Latino, Asian, and other subpopulations. 3. Mandate ongoing LGBTQIA+ cultural competency training that addresses stigma, implicit bias, and racism for APD and all public safety personnel. 4. Advocate for a state law that would ban the use of “gay panic” and “trans panic” legal defenses. A list of the 15 states that have enacted this type of legislation can be found here: Gay/Trans Panic Defense Laws. Copyright © 2021 Health Management Associates, Inc. 41 Thank You!! Charles Robbins, MBA Iliana Gilman, MPH Catherine Guerrero, MPH Michelle Parra, PhD Ryan Maganini 42 Copyright © 2021 Health Management Associates, Inc. 42