Health service use by same-sex attracted Australian women for alcohol and mental health issues: a cross-sectional study

Background Same-sex attracted women (SSAW) have higher rates of alcohol and mental health problems than heterosexual women, but utilisation of and satisfaction with treatment is limited. Aim This study investigated the influences on health service use for alcohol and mental health problems among SSAW. Design & setting The Gelberg-Andersen behavioural model of health service utilisation was used to generate outcome variables. Method A convenience sample of 521 community-connected Australian SSAW completed an online survey. Health service use according to sexual identity was compared using χ2 analysis. Binary logistic regression examined associations between the independent variables with treatment utilisation. Results Reports of alcohol treatment were very low. Only 41.1% of participants with service need had utilised mental health and alcohol treatment. Bisexual women (adjusted odds ratio [AOR] = 2.76) and those with ‘other’ identities (AOR = 2.38) were more likely to use services than lesbian women. Enablers to service use were having a regular GP (AOR = 3.02); disclosure of sexuality to the GP (AOR = 2.42); lesbian, gay, bisexual and transgender (LGBT) community-connectedness (AOR = 1.11); and intimate partner violence ([IPV] AOR = 2.51). Social support was associated with a reduction in treatment use (AOR = 0.97). Significant access barriers included not feeling ready for help, and previous negative experiences related to sexual identity. Conclusion Disclosing sexual identity to a regular, trusted GP correlated with improved utilisation of alcohol and mental health treatment for SSAW. The benefits of seeking help for alcohol use, and of accessing LGBT-inclusive GPs to do so, should be promoted to SSAW.


Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
Last summer our small medical team visited the Calais 'Jungle'.Since that time much has changed and the camp is being demolished and by the time this article is read, it will probably be long gone.Some youngsters are finally being brought to the UK under the 'Dubs' amendment.However, once this camp is cleared it will not solve the ongoing flight of refugees from war torn areas: other camps are already appearing.

July 2016
A young Afghan man caught his finger on a sharp point while trying to cross a barbed wire fence.The finger was partially degloved.He attended the local hospital, where they placed a few sutures, but now, 2 weeks later, the skin is necrotic and the underlying tissue looks infected.He is in danger of losing his finger.
A middle-aged Sudanese man has been having rigors and is generally unwell.He says it is similar to when he last had malaria.
A young Ukrainian woman complains of lower back pain and urinary frequency.The paths of these three people may never have crossed; yet here they are, denizens of the Calais Jungle.They turn up to a makeshift primary care 'clinic' that we set up in the heart of the unofficial refugee camp one weekend in July 2016.
With only basic medical supplies, we are immediately challenged by what we see.How can we arrange secondary care for the young Afghan in danger of losing his finger?We try to persuade him to return to the original local hospital, but he is reluctant.It was not a good experience for him the first time round.
With the other two patients, it is easier.They can attend the Salam clinic run by a local association during weekdays.Later, we receive word that malaria has been confirmed in our Sudanese patient.
More people arrive, presenting with scabies, rat bites, tinea, chest infections, and wheezing from inhaling smoke from fires lit to cook and keep warm in their tents at night.We examine a severely malnourished 2-year-old boy.We meet several of the camp's 600 unaccompanied children, at grave risk of sexual exploitation.We learn that there is inadequate safeguarding in place to protect them.A young Eritrean man comes in worried about his eye.He has sustained direct ocular trauma from a rubber bullet, and will never see normally again out of that eye.We see haematomas from police batons, and hear about children being exposed to tear gas again and again (Figure 1).

The reality
These are no ordinary patients.They have travelled far from home to escape war, poverty, and misery.They have endured personal odysseys to get here, experienced untold hardships, and suffered unimaginable privations.Many have survived the loss of their families, torture, and rape.Their journeys over, for the moment at least, they must make their homes in the Calais Jungle.Their new shelters are in many cases mere tarpaulin covers, and their new beds just rugs on the ground.They own next to nothing.There is little for them to do, besides use their ingenuity to cross the English Channel in search of a better life.They are vulnerable to exploitation, crime, injury, and disease.Potentially violent clashes with local police, with other ethnic groups resident in the Jungle, or local far Method: A convenience sample of 521 community-connected Australian SSAW completed an online survey.Health service use according to sexual identity was compared using c 2 analysis.Binary logistic regression examined associations between the independent variables with treatment utilisation.
Results: Reports of alcohol treatment were very low.Only 41.1% of participants with service need had utilised mental health and alcohol treatment.Bisexual women (adjusted odds ratio [AOR] = 2.76) and those with 'other' identities (AOR = 2.38) were more likely to use services than lesbian women.Enablers to service use were having a regular GP (AOR = 3.02); disclosure of sexuality to the GP (AOR = 2.42); lesbian, gay, bisexual and transgender (LGBT) community-connectedness (AOR = 1.11); and intimate partner violence ([IPV] AOR = 2.51).Social support was associated with a reduction in treatment use (AOR = 0.97).Significant access barriers included not feeling ready for help, and previous negative experiences related to sexual identity.

Conclusion:
Disclosing sexual identity to a regular, trusted GP correlated with improved utilisation of alcohol and mental health treatment for SSAW.The benefits of seeking help for alcohol use, and of accessing LGBT-inclusive GPs to do so, should be promoted to SSAW.

Introduction
2][3][4] Bisexual and 'mainly heterosexual' women demonstrate even higher risk than lesbian women.'Mainly heterosexual' signifies people who are same-sex attracted, but feel somewhere between bisexual and heterosexual in terms of their sexual identity. 5Mainly heterosexual young Australian women are significantly more likely than heterosexual women to report drinking >15 standard drinks per week, and mainly heterosexual and bisexual women were more likely to report binge drinking. 68][9] Problematic drinking is defined as drinking beyond levels set by national guidelines, and is generally defined by the research team or clinicians in the literature, rather than by the research participant.Problematic drinking is associated with stress, 10 depression, 11 childhood trauma, and sexuality-related discrimination. 12,13Sexual re-victimisation is also a strong predictor of problematic drinking, particularly for lesbian and mainly heterosexual women, 14 and alcohol use is strongly associated with IPV in lesbian couples. 15Gender-diverse and transgender (trans) people may also be same-sex attracted, or attracted to other gender-diverse people (pansexual).Currently, there are no population-based Australian data on drinking patterns among trans and gender-diverse people.
Higher rates of problematic drinking do not correlate well with treatment-seeking for alcoholrelated problems among SSAW. 6,16,17SSAW are consistently less likely than heterosexual women to use alcohol treatment services, despite reporting more problematic drinking. 3Seventy percent of Australian same-sex attracted people aged 18-25 years reported problematic alcohol use, but only 6% reported accessing any form of treatment. 13Mental healthcare utilisation can also be problematic.For example, a Canadian study found higher levels of unmet need for mental health care among trans women (2.4 times, P<0.01) and bisexual women (1.8 times, P = 0.02). 17][20] Women as a whole encounter barriers to accessing addiction services, which contributes to their seeking help online, 21 but there are compounding barriers for SSAW.Lesbian, gay, and bisexual (LGB) people in the US were more likely than heterosexual people to report 'perceptual' barriers to alcohol treatment, such as believing they should handle the problem alone, or that the problem was not serious enough. 4 LGB people also face discrimination and assumptions of heterosexuality that lead to poor communication and treatment planning. 22Alcohol treatment may be more accessible to SSAW if it is tailored specifically to their needs, 23 is culturally inclusive, and is 'gay affirmative.' 24Factors found to enable mental health care-seeking, that may also influence alcohol treatment, include having a regular GP, community-connectedness, 22 and disclosure of sexual identity to a supportive GP. [25][26][27] There is limited research that describes the relative factors influencing alcohol and mental health treatment-seeking.This study addressed this gap by applying the Gelberg-Andersen Behavioural Model for Vulnerable Populations to examine perceptual, structural, and social factors influencing SSAW's help-seeking. 28The model frames health service use as a function of predisposing, enabling, and need characteristics.Predisposing characteristics are those that 'exist prior to the perception of illness', and include age, gender, education, race, and victimisation.Enabling characteristics, such as income or social support, facilitate service access once illness has been perceived, or inhibit service access if lacking.Need characteristics include the type and severity of relevant health conditions. 29This study focused on characteristics specific to SSAW.The Gelberg-Andersen model has previously been used with SSAW in relation to treatment utilisation and alcohol and mental health disorders. 30Based on the literature, it was hypothesised that specific influences would vary according to predisposing characteristics (such as sexual identity and IPV history); enabling or inhibiting characteristics (for example, having a regular GP, level of social support,

Predisposing variables (Table 2)
Participants were asked their sexual identity: 'lesbian/gay', 'queer', 'bisexual', 'heterosexual/ straight', 'not sure or undecided', or 'I prefer to refer to myself as. ..'.These were recoded into lesbian/gay, bisexual, queer/pansexual, and 'other'.Queer identity tends to be more fluid and is distinct from lesbian or bisexual.Any heterosexual participants were included in the 'other' category.Participants were also asked their gender identity (for example, trans, genderqueer, or other).IPV was measured using three questions asking whether participants had ever been emotionally, sexually, or physically abused by a partner (in the past 12 months and before the past 12 months).Any abuse was regarded as IPV.

Research
Enabling and inhibiting characteristics (Table 3) The 19-item social support scale was used (score range = 0-76), with higher scores indicating greater social support (alpha = 0.97). 31An LGBT community-connectedness scale was created (not yet validated) using the following three items: 1 1. 'In how many LGBT community organisations are you a member?'; 2 2. 'How important is being a member of LGBT community organisations to you?' (possible answers: extremely, very, somewhat, a little, and not at all); 3 and 3. 'How often do you participate in LGBT community events?' (possible answers: daily, weekly, monthly, annually, and never).
Each item was treated as a 5-point scale (0-4).Responses to the three items were added (range = 0-12), with higher scores indicating greater connection to the LGBT community.Participants were also asked 'Have any of the following ever made you reluctant to seek help or advice about alcohol use?', followed by a list of common barriers drawn from the literature (Table 4).Participants could select 'yes, in the last 12 months', 'yes, more than 12 months ago', 'no, never', or 'other, please describe'.The same question was asked with regard to 'mental health and/or emotional wellbeing.'

Need variable
To understand the association between service use and enablers or inhibitors independent of service need, a 'health service need' control variable was created, which included participants who were positive for depression, problematic drinking, or suicide attempt within the past 12 months.Depression in the past 4 weeks was measured using the Centre for Epidemiological Studies Depression Scale-10 (CES-D-10); 32 those participants who scored 11 were considered to be depressed.

Research
Problematic drinking in the past 12 months was measured using the Alcohol Use Disorders Identification Test (AUDIT); participants scoring 8 were deemed to be 'problematic drinkers'. 33Suicidal thoughts and behaviour questions were 'Have you ever seriously thought about committing suicide?' and 'Have you ever attempted suicide?', with responses 'yes, in the last 12 months', 'yes, more than 12 months ago', and 'no, never'.Participants were not asked about self-perceived need for services.

Analyses
IBM SPSS Statistics (version 22) was used for data analysis.Pearson c 2 tests were used to examine sexual identity differences in study variables.Past 12-month treatment utilisation for mental health and alcohol-related problems were examined separately, using cross-tabulations according to sample demographic characteristics.Frequencies were calculated for the responses 'once' and 'more than once' in relation to use of each service.To examine barriers to treatment utilisation, frequencies were calculated for participants who were positive for 'service need' (n = 314).Binary logistic regression models were tested using 'treatment utilisation' as the outcome.The following independent variables were included simultaneously: 'social support', 'having a regular GP', 'disclosure of sexuality to GP', 'ever experienced or feared discrimination within health services', 'sexual orientation', and 'IPV'.Correlations were examined among the independent variable to Research check for multicollinearity.Analyses controlled for service need and low income, as these were found to be correlated with the outcome variable and at least one independent variable at the P<0.05 level.Education, age, and parental status were also considered as potential control variables, but none were correlated with the outcome variable, and were therefore not included in further analyses.

Results
As summarised in Table 2, nearly two-thirds (n = 314, 60.3%) of the sample was positive for service need, and 271 (52.0%) had received treatment for mental health or alcohol use in the last year.Of those positive for service need, only 185 (58.9%) had utilised treatment.Of participants who received services, 8 (1.5%) utilised services for alcohol use alone, 205 (39.3%) utilised services for mental health alone, and 58 (11.1%) utilised services for both alcohol and mental health concerns.Table 1 describes health providers seen for mental health or alcohol use-related concerns.The most utilised types of service providers were counsellor, psychologist, or psychiatrist.Of the 206 participants who sought help from these providers for mental health, 91.3% (n = 188) attended more than once in the past year, indicating some level of continuity of care.GPs were the next most frequently used, but only 68.9% (n = 135) had seen the GP more than once for mental health issues.In the Australian healthcare system, GPs are the main access point for publicly subsidised counselling or psychiatrist visits, so some of the GP access will have been to seek a referral, rather than for ongoing care for mental health with the GP.Very few of the participants had utilised care for alcohol issues, with only 7.1% (n = 37) seeing mental health providers and 4.0% (n = 21) seeing GPs.A minority of participants (n = 62, 11.9%) reported having attended LGBT-specific services for mental health; and 16 (3.1%)attended LGBT-specific services for alcohol-related problems.
Comparison of service use according to sexual identity shows some differences in relation to provider types.Significant differences were found for having a GP ('lesbian/gay' participants were more likely P = 0.001), and the GP knowing sexual identity ('lesbian/gay' participants were more likely P = 0.000), and reluctance to use services for mental health ('queer/pansexual' participants were more reluctant P = 0.000).There were no differences by sexual identity in reluctance to use services for alcohol use.The use of services at least once in the past 12 months for alcohol use or for mental health also showed no difference by sexual identity.Comparison of LGBT community-connection differed, with bisexual participants much more likely to have never connected (39.3%, n = 34) than lesbian (23.2%, n = 66) or queer/pansexual (18.2%, n = 17; P = 0.000) women.
Barriers to seeking help for those with service need are listed in Table 4.The most frequently reported barrier was concern about mental health or alcohol use being judged (38.7%, n = 116).The second most frequent barrier was not feeling ready to seek help (38.0%,n = 114), and several

Research
participants also indicated that they did not feel the need for help.Fear or actual experiences of discrimination was the least reported barrier.While only 16.3% (n = 49) selected fear of discrimination, analysis of the 'other' responses from participants revealed that the majority were related to negative past healthcare experiences, or not being able to find LGBT-specific services.This indicates that sexual identity was an important barrier even if discrimination in health care per se was not an issue.Experiences of discrimination were common, and significantly differed according to sexual identity.More bisexual (80.9%, n = 70) and lesbian (70.7%, n = 204) than queer/pansexual (51.5%, n = 50, P = 0.000) individuals had experienced discrimination in the past year.Tests to understand associations with treatment use showed similar levels of association individually for mental health and alcohol-related help, so results of the regression models are presented together (Table 3).All independent variables except 'discrimination within health services ever' were significantly associated with treatment use (P<0.05).The strongest positive associations, in order, were 'having a regular GP', 'bisexual identity', 'IPV', 'disclosure of sexuality to GP', and 'LGBT community-connectedness'.Greater social support was associated with reduced likelihood of health service use.Bisexual women (AOR = 2.76, P = 0.001) and those with an 'other identity' (AOR = 2.38, P = 0.046) were more likely to utilise health services than lesbian women, even when controlling for health need.The difference in service use between queer and lesbian participants was not statistically significant (P = 0.189).

Summary
This study identified very low levels of service use for alcohol-related problems, despite high levels of risky drinking.The hypotheses that specific influences on help-seeking would include sexual identity, IPV, and GP support were largely supported.In particular, bisexual women were most likely to utilise health care, but less likely to connect with the LGBT community than lesbian women.It was found that barriers to service use varied by sexual identity, and that GP engagement and LGBT community-connection were strong enablers for health service use.The authors did not expect higher levels of social support to be related to reduced service use.It is likely that people with strong social support were less likely to perceive the need for professional support.

Strengths and limitations
A strength of the study is its description of health services barriers and facilitators to healthcare use, which may be used to develop health promotion initiatives targeted to specific sub-groups of SSAW.Nevertheless, the study had limitations that should be considered.A volunteer sample was used, recruited largely through LGBT social media.SSAW who were more socially isolated or who were not connected with the LGBT community may be under-represented, limiting generalisability of findings.For example, some bisexually active women identify as heterosexual and do not necessarily connect with LGBT social media. 34Although collecting data online facilitated the recruitment of a geographically diverse sample, only those with sufficient computer literacy and internet access could participate.The sample may also under-represent some responders in need of health services, as anxiety or physical health were not assessed.Defining problematic drinking based on the AUDIT rather than self-perception also limited the ability to assess whether failing to perceive drinking as a problem was a barrier to help-seeking.Finally, although participants were asked about their gender identity, the number of trans and gender-diverse people was too small to analyse separately, and the focus for this study was sexual identity.Gender diversity is an important area for future research especially because health care is often delayed due to fears or previous experiences of discrimination in this population group. 35

Comparison with existing literature
Previous researchers have also found low levels of help-seeking for alcohol-related problems among SSAW.One study using the Gelberg-Andersen model to investigate access to HIV prevention services found that consumption of alcohol was negatively associated with help-seeking. 36One possible reason for low levels of alcohol treatment in primary care is limited enquiry about alcohol intake by GPs. 37However, primary care is well-placed to provide initial alcohol screening and brief Research intervention in an affirming environment. 38Key barriers to help-seeking for alcohol and mental health in this study were fears of being judged about alcohol use or mental health issues.While the literature suggests fear of sexual identity-based discrimination as a barrier, in the present study, other negative experiences in health care were more problematic.An affirming clinician response to sexual identity disclosure may encourage disclosure of more troubling issues, such as those related to problematic drinking or mental health concerns, but a discriminatory or dismissive response is likely to create more barriers. 25onnection to LGBT community was associated with greater treatment utilisation.This is consistent with previous research findings indicating that mental health help-seeking may be less stigmatised and therefore more likely to be encouraged among SSAW compared with heterosexual women. 2,30It may be that connection to the LGBT community encourages help-seeking, perhaps by increasing access to information about LGBT-inclusive services.Conversely, social support was negatively associated with health service use in this study.This is counter to the Gelberg-Andersen model that predicts social support as an enabler of health service use. 28,30Others have noted that social support reduces the need for mental health services. 39Perhaps participants with good social support in this study sought help for their mental health or alcohol-related problems preferentially through social networks rather than health services.Other Australian research has found peer support groups to be commonly used for mental health concerns, although professional help was more likely when mental health problems were more severe. 22These findings can be used in targeted health promotion messages that encourage professional help-seeking for alcohol and mental health concerns.
IPV was also strongly associated with mental health and alcohol treatment utilisation.IPV may be at least as common among same-sex as heterosexual couples, although this is an under-researched and under-recognised problem in the LGBT community. 40Possible explanations for the association between IPV and help-seeking include the potential compounding effect of IPV on mental health and substance use problems, which increases the need for help. 15In addition, SSAW's disclosure of IPV to a treatment provider often necessitates disclosure of a same-sex relationship.If disclosure of these two potentially stigmatised issues is met with a positive response, SSAW may be more likely to disclose concerns related to mental health and alcohol use.General practice plays a 'critical role' for victims of IPV, and enablers include positive GP communication skills and time, careful management of disclosure, and sense of safety. 41These may be even more important for SSAW.

Implications for research and practice
General practice has a strong role to play in the health care of SSAW.Having a regular GP was strongly correlated with alcohol and mental health treatment utilisation.Previous findings suggest that having a regular GP is associated with increased healthcare utilisation in general. 42In Australia, GPs both provide alcohol-related and mental health care, and enable referral for publicly rebated specialist services, 43 so having a regular GP should be associated with increased use of services for mental health and alcohol problems.Very few participants utilised services for mental health without seeing a GP.This finding is important in the context of previous research suggesting that SSAW are less likely to have a regular GP compared with heterosexual women, and are less satisfied with the care received. 44Similarly, in a large-scale Canadian probability sample, bisexual and lesbian women were much more likely than heterosexual women to have no regular doctor. 45Therefore, enabling SSAW to have a regular GP could improve service use for mental health and alcohol concerns.
7][48][49] The association between service use and disclosure to one's GP may have several explanations.It may be that regular visits increase SSAW's comfort with their GP, as well as opportunities for disclosure. 25Further, if disclosure of sexual identity is sensitively received, this may facilitate disclosure of other sensitive or stigmatised issues such as IPV, mental health problems, and substance use.Previous research has found that LGBT people with mental health or substance use concerns prefer to have their sexual orientation acknowledged and integrated into the management process. 50inally, differences in enablers and barriers to treatment-seeking according to sexual identity could be considered when creating more tailored approaches to health promotion for diverse groups of SSAW.For example, bisexual women were less likely to have a regular GP and to be connected to the LGBT community, both of which were positively associated with utilisation of

Table 1 .
Twelve-month treatment utilisation for mental health and alcohol-related problems by service provider

Table 2 .
Sample demographics by 12-month treatment utilisation for mental health and alcohol-related problems SD = standard deviation.Trans = transgender.

Table 3 .
Binary logistic regression model of influences on past-year treatment utilisation for mental health or alcohol-related problems a Sample size = 452, missing data = 69 (cases were excluded if data was missing for at least one variable).CI = confidence interval.IPV = intimate partner violence.OR = odds ratio.SD = standard deviation.

Table 4 .
Barriers to treatment utilisation for mental health and alcohol-related problems among those in need of services (based on high CES-D-10, AUDIT score, or suicide attempts within 12 months) Reluctant to seek help or advice for alcohol use or mental health within the previous 12 months due to the stated reason, n (%) AUDIT = Alcohol Use Disorders Identification Test.CES-D-10 = Centre for Epidemiological Studies Depression Scale-10.