In this paper, I will discuss the different types of discrimination that LGBT youths are faced with and the effects on these youths. The paper will elaborate on the severe impacts on LGBT youths not only caused by discrimination but also due to lack of support and guidance. The paper will also discuss the roles of the parents and schools in helping minimize discrimination against LGBT youths. This paper will also hopefully instruct schools and parents to accept and support gay students rather than add to the discrimination that they already face. Doing so will reduce the high school drop out rate and most importantly the youth suicide rate. In essence, the purpose of this research paper is to identify the different effects on LGBT youths due to discrimination and to explore various actions that can and should be taken by schools and parents to help these youths live a normal and happy life. Therefore, my target audience is the school system as well as the parents of LGBT youths.
Suicide is the leading cause of death among gay and lesbian youths. Gay and lesbian youths are 2 to 6 times more likely to attempt suicide than heterosexual youth. Over 30% of all reported teen suicides each year are committed by gay and lesbian youths. . . . Gays and lesbians are at much higher risk than the heterosexual population for alcohol and drug abuse. Approximately 30% of both the lesbian and gay male populations have problems with alcohol. Gay and lesbian youth are at greater risk for school failure than heterosexual children. (U.S. Department of Health and Human Services, 1989, as cited in “Today’s Gay Youth,” n.d., n.p.)
Substantially higher proportions of homosexual people use alcohol, marijuana or cocaine than is the case in the general population. (McKirnan & Peterson, 1989, as cited in “Today’s Gay Youth,” n.d., n.p.)
Approximately 28% of gay and lesbian youths drop out of high school because of discomfort (due to verbal and physical abuse) in the school environment. (Remafedi, 1987, as cited in “Today’s Gay Youth,” n.d., n.p.)
Gay and lesbian youths’ discomfort stems from fear of name calling and physical harm. (Eversole, n.d, as cited in “Today’s Gay Youth,” n.d., n.p.)
Many people are guilty of discrimination against LGBT youths, whether consciously or unconsciously. LGBT youths are faced with daily discrimination from society, peers, family and even school teachers and administrations. The above statistics not only show that LGBT youths lack support and guidance but also prove how much these youths are clearly affected, in more ways than one, by discrimination. Cole (2007) mentions that there is a higher rate of abuse, neglect, and discrimination against LGBT youths than straight youths. I believe that most parents would prefer their children to be straight than to be gay, and most school officials also prefer straight students over gay students. This preference could be a contributing factor in discrimination against LGBT youths. This paper will hopefully capture the attention of parents and schools and perhaps help modify their outlook on LGBT youths. Fundamentally, I will attempt to answer the following questions throughout the paper: What are the effects of discrimination against LGBT youths? What is the role of the parents? What is the role of the schools? How can parents and schools work together to help minimize discrimination against LGBT youths? What more can be done? Before answering those questions, I will start by addressing the types of discrimination that LGBT youths are faced with.
Types of Discrimination
Some of the comments that LGBT youths are faced with are as follows: “I hate gays. They should be banned from this country;” “Get away from me, you faggot. I can’t stand the sight of you;” “These queers make my stomach turn.” Those are only a few of the biased statements that LBGT youths are faced with in society. According to Cole (2007), the word “faggot” is often used by anti-gay peers to terrorize LGBT youths. Words such as “faggot” or “gay” are sometimes used in a negative sense to express something either stupid or uncool (Human Rights Watch, 2001, p.35). When that occurs, it shows an even greater sign of discrimination against LGBT youths. I noticed that these words are not only used in the real world but also in movies and TV shows which makes it harder for LGBT youths to deal with. In addition to the discrimination from society and their peers, LGBT youths also endure discrimination from home/families and particularly schools.
“Today’s Gay Youth: The Ugly, Frightening Statistics” (n.d.) reports that one half of LGBT youths are neglected by their parents because of their sexual preference and approximately a quarter of LGBT youths are mandated to leave their homes. Cole (2007) explains that rejected LGBT youths generally do not learn how to build a relationship with peers or families. As a result, it creates a state of loneliness and isolation for them. Some LGBT youths are both verbally and physically abused by parents (“Today’s Gay Youth,” n.d.). In addition, roughly about 40% of youths that are homeless are classified as LGBT youths. The same article shows 27% of male teenagers who classified themselves as gay or bisexual left home due to quarrels with family members over their sexuality. Needless to say, parents and families play a big part in discrimination against LGBT youths and the effects that it has on them.
Nevertheless, it appears that the majority of the discrimination against LGBT youths emanates from the schools that they attend. Are schools taking any actions to minimize discrimination against gay students? What are they doing to help these adolescents? The following quote is an explicit example of how schools can contribute to discrimination against LGBT youths:
I took a call from one sixteen-year-old who came out to his counselor. The only other person he’d told was his friend in California. The counselor said, “I can’t help you with that.” After he left, the counselor called his mother to make sure she knew. The youth went home that night not knowing that he’d been outed to his parents. Sitting around the dinner table, his mother said to him, “I got a call from the school counselor today. We’re not going to have any gay kids in this family.” His father took him outside and beat him. (as cited in Human Rights Watch, 2001, p.106)
Human Rights Watch (2001) also reports that the same youth was harassed by his peers once they found out about his sexuality. At this point he turned to suicide, but was fortunately taken in by a family member who lived out of state where he finished school (p. 106). In the mentioned quote, the sixteen-year-old student did not get any support from his school guidance counselor or his parents. If his own school and parents would not give him any guidance or support, who else could he turn to? What is the alternative? This example could be a common concern throughout the world, where LGBT youths are not comfortable with their gender at school at home. Consequently, they are faced with an alternative which is rarely a positive one. The alternatives that they face may include depression, substance abuse, violence, and even suicide.
Effects of Discrimination
LGBT youths endure hostile verbal and physical harassment that can be excruciating for them (Human Rights Watch, 2001, p. 35). Human Rights Watch (2001) also states that although the youths that were interviewed emphasized their fear of physical and sexual assault, being called words like “faggot,” “queer,” or “dyke,” daily is still destructive (p.35).
One young gay youth who had dropped out of an honors program angrily protested, “just because I am gay doesn’t mean I am stupid,” as he told of hearing “that’s so gay” meaning “that’s so stupid,” not just from other students but from teachers in his school. (Human Rights Watch, 2001, p. 35)
Over 25% of LGBT youths are high school drop outs because of the discrimination they are faced with in the school atmosphere (“Today’s Gay Youth,” n.d.). The article also states the LGBT youths have a greater risk of academic failure than heterosexual students. Furthermore they don’t get involved much in student activities and have very little dedication to the school’s agendas because school isn’t a safe, healthy, or productive learning environment. Therefore, LGBT youths make an attempt to live, work, and learn with continuous fear of physical assault at school (“Today’s Gay Youth,” n.d.).
Physical abuse against LGBT youths usually occurs due to disregarded harassment (Human Rights Watch, 2001, p. 42). Human Rights Watch (2001) says that the number of physical assaults that were reported by interviewed LGBT youths had an enormous psychological impact on them, mainly because the physical abuse followed constant verbal and non-physical harassment that was overlooked by school officials (p. 42). For example, a lesbian student reported that several months of harassment and verbal threats grew to physical abuse. “‘I got hit in the back of the head with an ice scraper.’ By that point, she said she was so used to being harassed. ‘I didn’t even turn around to see who it was’” (Human Rights Watch, 2001, p. 42). Another incident mentioned by Human Rights Watch (2001) involved a tenth grade gay youth who was hit in the back of the neck with a beer bottle. He literally had to crawl to the nearest friend’s house for immediate assistance. The same youth was beaten up in the seventh grade by a couple of anti-gay kids (p. 42). One last example entails another gay youth who first suffered from verbal assault and students throwing items at him. Subsequently, a group of anti-gay students strangled him with a drafting line so bad that it cut him. Later that school year the youth was dragged down a flight of stairs and cut with knives by his classmates (Human Rights Watch, 2001, p. 42). Fortunately, he lived to talk about it.
Human Rights Watch (2001) implies that verbal and physical violence is a tension that LGBT youths have gotten accustomed to; however, it is damaging to their psychological wellbeing (p. 68). Many of the LGBT youths interviewed by Human Rights Watch (2001) reported signs of depression such as: “sleeplessness, excessive sleep, loss of appetite, and feeling of hopelessness”(p. 69). One reported incident involved a gay youth who could not take it anymore. He started to skip school so that he would not have to put up with the harassment anymore. He stayed at home all day and ended up missing fifty-six days of school. The youth explained, “‘It was mentally and physically stressful for me to go to that school. I remember going home and waking up in the morning just dreading it; dreading the fact that I would have to go back to that school’” (as cited in Human Rights Watch, 2001, p. 69). Other youths reported that even when the harassment was not addressed directly toward them, they were affected by it. One youth implied that discrimination and harassment makes him feel like he is backed up into a corner and so sad that he wants to cry (Human Rights Watch, 2001, p. 69). It is no wonder LGBT youth turn to drugs, alcohol, and suicide.
Cole (2007) claims that discrimination against LGBT youths can create repression along with a deficiency in their natural growth. Discrimination also has a social and emotional impact on them. Instead of being social individuals, LGBT youths remain in the closet and hide. The loneliness that they bear can turn into depression which often leads to substance abuse or even suicide. LGBT youths have greater chances of alcohol and substance abuse than heterosexual youths (U.S. Department of Health and Human Services, 1989, as cited in “Today’s Gay Youth,” n.d.). Also, roughly about one third of LGBT youths have a drinking or drug problem. Human Rights Watch (2001) interviewed some LGBT youths who say that they drink to the point of passing out or to feel good and normal (p. 69). The lack of support from parents or schools can possibly make them feel like there is no hope of ever living a happy life and being productive (Human Rights Watch, 2001, p. 68).
Roles of Parents
50% of all gay and lesbian youths report that their parents reject them due to their sexual orientation. In a study of male teenagers self-described as gay or bisexual, 27% moved away from home because of conflict with family members over sexual orientation. (Remafedi, 1987, as cited in “Today’s Gay Youth,” n.d., n.p.)
26% of gay and lesbian youth are forced to leave home because of conflicts over their sexual orientation. (U.S. Department of Health and Human Services, 1989, as cited in “Today’s Gay Youth,” n.d., n.p.)
In a study of 194 gay and lesbian youth, 25% were verbally abused by parents, and nearly 10% dealt with threatened or actual violence. (D’Augelli, 1997, as cited in “Today’s Gay Youth,” n.d., n.p.)
Approximately 40% of homeless youths are identified as gay, lesbian or bisexual. (Eversole, n.d., as cited in “Today’s Gay Youth,” n.d., n.p.)
Service providers estimate that gay, lesbian and bisexual youths make up 20-40% of homeless youth in urban areas. (National Network of Runaway and Youth Services, 1991, as cited in “Today’s Gay Youth,” n.d., n.p.)
It appears that the lack of support, protection, and guidance from family also has a major effect on LGBT youths. Perhaps, if their families were more supportive, the suicide and depression rates of LGBT youths would be moderately less. I believe that parents should embrace their children no matter what their sexual preference is. For an adolescent, I think that family should be the primary source for seeking support and guidance. When parents reject their gay or lesbian adolescent, I feel that it can possibly set him or her up for failure. This era is the time when adolescents would need their parents’ love and support the most. I also sense that when LGBT youths don’t get the love and support that they are looking for from parents, it contributes to their state of depression and suicidal phase. Therefore, parents of LGBT youths should take time to reflect on the circumstances before they make the wrong decisions.
One way of showing support would be for the youths’ parents or family to intervene with the school or at least make an attempt like the mother in the following quote:
“The more I talked to teachers, the superintendent, and the principal, the more they just kept throwing up brick walls and trying to convince me I would have to let my son go through this,” Ms. Cooper said. “But no child should have to go through this, whether he’s gay or not. When [bullying] gets to the point where a kid wants to quit school and give up his future, something has to be done.” (Browman, 2001, p. 3)
In the above case, the parent was being supportive to her gay son while the school officials were not. Like many other schools, they choose to ignore the fact that the gay student is being bullied and discriminated against. As mentioned earlier in the paper, that kind of response from schools also contributes to the effects of depression on LGBT youths.
Roles of Schools
“Educators cannot ignore the risks faced by homosexual students, but deciding how to deal with the issue should be a matter of local concern” (Archer, 2002, n.p.). In his article, Archer is stressing that educators must address discrimination against gay students and must put aside their personal views to create a safe environment for these students. In her article, Browman (2001) also talks about the lack of attention from school teachers and administrators toward gay discrimination and harassment. Browman (2001) acknowledges the educational effect on LGBT youths due to constant harassment in school. A very interesting point that was made in this article is, if a student makes a racial comment in school, he or she gets punished. So why should remarks like “dyke,” “fag,” or “queer” be acceptable? Are those words equal to the same level of discrimination as making a racial comment? The article advises that the problem of discrimination or harassment can be addressed at the verbal stage before it gets to the physical point or causes the youth’s academic learning to be harmed (Browman, 2001). The article continues to imply that teachers and administrators often fail to cease discrimination or harassment against LGBT youth. They are either afraid of facing prejudice from others or perhaps even because of their own prejudice (Browman, 2001). The article also suggests a way to express to all students that harassment or discrimination against LGBT students will not be tolerated. Consequences such as school conduct codes and discipline policies should be established as well as anti-harassment rules (Browman, 2001).
Browman (2001) reports that Human Rights Watch completed a two-year study on the topic where an immediate response was obtained from educational groups such as: The National Education Association, The Gay, Lesbian, and Straight Educational Alliance, and The American Federation of Teachers. The three groups adhered in influencing the Education Department to defend and protect gay and lesbian students from discrimination. They add that schools are making an effort to create a safe environment for all students where they can all be treated with equal respect and dignity. Accordingly, the department fights to provide the schools with information and guidance to help solve the problem of discrimination against LGBT youths (Browman, 2001).
Furthermore, New York City has made an attempt to come up with a solution that they thought would possibly reduce discrimination against LGBT youths by opening an all-gay school. I see this movement as a possible increase in discrimination against LGBT youths. If they are all put together in one school, how is that helping them deal with discrimination from society, peers and others outside of the school? And how is that teaching anti-gay students not to discriminate against LGBT youths? I don’t think isolation from the rest of the world is the best solution for LGBT youths. They are human beings just like the rest of us and they should be treated accordingly. I agree with what is stated in Browman’s (2001) article about the schools accomplishing all they can to stop discrimination against LGBT youths.
The two primary sources that have the power and ability to diminish discrimination against LGBT youths are schools and parents. In my opinion, they are the ones who have the greatest influence on LGBT youths and in turn have the ability to reduce substance abuse, educational failure, and suicides. Parents and schools need to realize how much they can help diminish the effects of discrimination against LGBT youths if they work together and productively. Clearly, if they remain on the same page they can ease the agony for LGBT youths and help them live a normal and happy life. One method that can be exercised in schools is a homosexual sensitivity training for anti-gay students and school officials. The training would benefit both students and school officials. I think that it would help the school officials manage whatever prejudices they may have against LGBT youths. Since anti-gay bullying students are perhaps ignorant to the subject, schools should modify a system where all students can be educated on the subject. It would probably help the students get a better understanding if homosexuality was compared to other subject matters such as culture and religion. Students should be provided with a full view of the subject just like any other. If this method helps only two out of ten anti-gay students cease discrimination against LGBT students, I am sure that it will make a difference. An additional scheme that should be established is monthly meetings between school officials and parents to review the progress of measures that are already in place.
Before writing this research paper, I never imagined how immensely affected LGBT youths were by discrimination. It is awful what they go through and how most people are clueless or even careless about what these youths endure. LGBT youths are faced with discrimination, torture, and sometimes even execution because of who they love, how they look, or who they are. I believe that sexual orientation and gender identity are integral aspects of ourselves and should never lead to discrimination or abuse. Doing this research not only made me realize the intense discrimination suffered by LGBT youths but also had an impact on me. This research has made me want to advocate for more laws and policies to help protect LGBT youths. I have gained a ton of information and knowledge during this process. However, if my readers obtain half of the valuable information that I have obtained, I know that I have accomplished my task.
Archer, J. (2002, February). Local schools must address safety for gays. Education Week, 21 (23), 3. Retrieved October 12, 2007, from EBSCO Host database.
Browman, D. H. (2001, June). Report says schools often ignore harassment of gay students. Education Week, 20 (39), 5. Retrieved October 12, 2007, from EBSCO Host database.
Cole, S. (2007, April). Protecting our youth. Edge . Retrieved October 31, 2007, from www.edgeboston.com
Human Rights Watch (2001). Hatred in the hallways. NY: Human Rights Watch.
Today’s gay youth: The ugly, frightening statistics (n.d.). Retrieved October 31, 2007, from www.pflagphoenix.org
At a time when lesbian, gay, bisexual, and transgender (LGBT) individuals are an increasingly open, acknowledged, and visible part of society, clinicians and researchers are faced with incomplete information about the health status of this community. Although a modest body of knowledge on LGBT health has been developed over the last two decades, much remains to be explored. What is currently known about LGBT health? Where do gaps in the research in this area exist? What are the priorities for a research agenda to address these gaps? This report aims to answer these questions.
THE LGBT COMMUNITY
The phrase “lesbian, gay, bisexual, and transgender community” (or “LGBT community”) refers to a broad coalition of groups that are diverse with respect to gender, sexual orientation, race/ethnicity, and socioeconomic status. Thus while this report focuses on the community that is encapsulated by the acronym LGBT, the committee wishes to highlight the importance of recognizing that the various populations represented by “L,” “G,” “B,” and “T” are distinct groups, each with its own special health-related concerns and needs. The committee believes it is essential to emphasize these differences at the outset of this report because in some contemporary scientific discourse, and in the popular media, these groups are routinely treated as a single population under umbrella terms such as LGBT. At the same time, as discussed further below, these groups have many experiences in common, key among them being the experience of stigmatization. (Differences within each of these groups related to, for example, race, ethnicity, socioeconomic status, geographic location, and age also are addressed later in the chapter.)
Lesbians, gay men, and bisexual men and women are defined according to their sexual orientation, which, as discussed in Chapter 2, is typically conceptualized in terms of sexual attraction, behavior, identity, or some combination of these dimensions. They share the fact that their sexual orientation is not exclusively heterosexual. Yet this grouping of “nonheterosexuals” includes men and women; homosexual and bisexual individuals; people who label themselves as gay, lesbian, or bisexual, among other terms; and people who do not adopt such labels but nevertheless experience same-sex attraction or engage in same-sex sexual behavior. As explained throughout the report, these differences have important health implications for each group.
In contrast to lesbians, gay men, and bisexual men and women, transgender people are defined according to their gender identity and presentation. This group encompasses individuals whose gender identity differs from the sex originally assigned to them at birth or whose gender expression varies significantly from what is traditionally associated with or typical for that sex (i.e., people identified as male at birth who subsequently identify as female, and people identified as female at birth who later identify as male), as well as other individuals who vary from or reject traditional cultural conceptualizations of gender in terms of the male–female dichotomy. The transgender population is diverse in gender identity, expression, and sexual orientation. Some transgender individuals have undergone medical interventions to alter their sexual anatomy and physiology, others wish to have such procedures in the future, and still others do not. Transgender people can be heterosexual, homosexual, or bisexual in their sexual orientation. Some lesbians, gay men, and bisexuals are transgender; most are not. Male-to-female transgender people are known as MtF, transgender females, or transwomen, while female-to-male transgender people are known as FtM, transgender males, or transmen. Some transgender people do not fit into either of these binary categories. As one might expect, there are health differences between transgender and nontransgender people, as well as between transgender females and transgender males.
Whereas “LGBT” is appropriate and useful for describing the combined populations of lesbian, gay, bisexual, and transgender people, it also can obscure the many differences that distinguish these sexual- and gender-minority groups. Combining lesbians and gay men under a single rubric, for example, obscures gender differences in the experiences of homosexual people. Likewise, collapsing together the experiences of bisexual women and men tends to obscure gender differences. Further, to the extent that lesbian, gay, and bisexual are understood as identity labels, “LGB” leaves out people whose experience includes same-sex attractions or behaviors but who do not adopt a nonheterosexual identity. And the transgender population, which itself encompasses multiple groups, has needs and concerns that are distinct from those of lesbians, bisexual women and men, and gay men.
As noted above, despite these many differences among the populations that make up the LGBT community, there are important commonalities as well. The remainder of this section first describes these commonalities and then some key differences within these populations.
Commonalities Among LGBT Populations
What do lesbians, gay men, bisexual women and men, and transgender people have in common that makes them, as a combined population, an appropriate focus for this report? In the committee's view, the main commonality across these diverse groups is their members' historically marginalized social status relative to society's cultural norm of the exclusively heterosexual individual who conforms to traditional gender roles and expectations. Put another way, these groups share the common status of “other” because of their members' departures from heterosexuality and gender norms. Their “otherness” is the basis for stigma and its attendant prejudice, discrimination, and violence, which underlie society's general lack of attention to their health needs and many of the health disparities discussed in this report. For some, this “otherness” may be complicated by additional dimensions of inequality such as race, ethnicity, and socioeconomic status, resulting in stigma at multiple levels.
To better understand how sexuality- and gender-linked stigma are related to health, imagine a world in which gender nonconformity, same-sex attraction, and same-sex sexual behavior are universally understood and accepted as part of the normal spectrum of the human condition. In this world, membership in any of the groups encompassed by LGBT would carry no social stigma, engender no disgrace or personal shame, and result in no discrimination. In this world, a host of issues would threaten the health of LGBT individuals: major chronic diseases such as cancer and heart disease; communicable diseases; mental disorders; environmental hazards; the threat of violence and terrorism; and the many other factors that jeopardize human “physical, mental and social well-being.”1 By and large, however, these issues would be the same as those confronting the rest of humanity. Only a few factors would stand out for LGBT individuals specifically. There would be little reason for the Institute of Medicine (IOM) to issue a report on LGBT health issues.
We do not live in the idealized world described in this thought experiment, however. Historically, lesbians, gay men, bisexual individuals, and transgender people have not been understood and accepted as part of the normal spectrum of the human condition. Instead, they have been stereotyped as deviants. Although LGBT people share with the rest of society the full range of health risks, they also face a profound and poorly understood set of additional health risks due largely to social stigma.
While the experience of stigma can differ across sexual and gender minorities, stigmatization touches the lives of all these groups in important ways and thereby affects their health. In contrast to members of many other marginalized groups, LGBT individuals frequently are invisible to health care researchers and providers. As explained in later chapters, this invisibility often exacerbates the deleterious effects of stigma. Overcoming this invisibility in health care services and research settings is a critical goal if we hope to eliminate the health disparities discussed throughout this report.
It is important to note that, despite the common experience of stigma among members of sexual- and gender-minority groups, LGBT people have not been passive victims of discrimination and prejudice. The achievements of LGBT people over the past few decades in building a community infrastructure that addresses their health needs, as well as obtaining acknowledgment of their health concerns from scientific bodies and government entities, attest to their commitment to resisting stigma and working actively for equal treatment in all aspects of their lives, including having access to appropriate health care services and reducing health care disparities. Indeed, some of the research cited in this report demonstrates the impressive psychological resiliency displayed by members of these populations, often in the face of considerable stress.
As detailed throughout this report, the stigma directed at sexual and gender minorities in the contemporary United States creates a variety of challenges for researchers and health care providers. Fearing discrimination and prejudice, for example, many lesbian, gay, bisexual, and transgender people refrain from disclosing their sexual orientation or gender identity to researchers and health care providers. Regardless of their own sexual orientation or gender identity, moreover, researchers risk being marginalized or discredited simply because they have chosen to study LGBT issues (Kempner, 2008), and providers seldom receive training in specific issues related to the care of LGBT patients. In addition, research on LGBT health involves some specific methodological challenges, which are discussed in Chapter 3.
Differences Within LGBT Populations
Not only are lesbians, gay men, bisexual women and men, and transgender people distinct populations, but each of these groups is itself a diverse population whose members vary widely in age, race and ethnicity, geographic location, social background, religiosity, and other demographic characteristics. Since many of these variables are centrally related to health status, health concerns, and access to care, this report explicitly considers a few key subgroupings of the LGBT population in each chapter:
Age cohort—One's age influences one's experiences and needs. Bisexual adolescents who are wrestling with coming out in a nonsupportive environment have different health needs than gay adult men who lack access to health insurance or older lesbians who are unable to find appropriate grief counseling services. In addition, development does not follow the same course for people of all ages. An older adult who comes out as gay in his 50s may not experience the developmental process in the same fashion as a self-identified “queer” youth who comes out during her teenage years. Similarly, as discussed further below, experiences across the life course differ according to the time period in which individuals are born. For example, an adolescent coming out in 2010 would do so in a different environment than an adolescent coming out in the 1960s. Moreover, some people experience changes in their sexual attractions and relationships over the course of their life. Some transgender people, for example, are visibly gender role nonconforming in childhood and come out at an early age, whereas others are able to conform and may not come out until much later in life.
Race and ethnicity—Concepts of community, traditional roles, religiosity, and cultural influences associated with race and ethnicity shape an LGBT individual's experiences. The racial and ethnic communities to which one belongs affect self-identification, the process of coming out, available support, the extent to which one identifies with the LGBT community, affirmation of gender-variant expression, and other factors that ultimately influence health outcomes. Members of racial and ethnic minority groups may have profoundly different experiences than non-Hispanic white LGBT individuals.
Educational level and socioeconomic status—An LGBT individual's experience in society varies depending on his or her educational level and socioeconomic status. As higher educational levels tend to be associated with higher income levels, members of the community who are more educated may live in better neighborhoods with better access to health care and the ability to lead healthier lives because of safe walking spaces and grocery stores that stock fresh fruits and vegetables (although, as discussed in later chapters, evidence indicates that some LGBT people face economic discrimination regardless of their educational level). On the other hand, members of the LGBT community who do not finish school or who live in poorer neighborhoods may experience more barriers in access to care and more negative health outcomes.
Geographic location—Geographic location has significant effects on mental and physical health outcomes for LGBT individuals. Those in rural areas or areas with fewer LGBT people may feel less comfortable coming out, have less support from families and friends, and lack access to an LGBT community. LGBT individuals in rural areas may have less access to providers who are comfortable with or knowledgeable about the treatment of LGBT patients. In contrast, LGBT people living in areas with larger LGBT populations may find more support services and have more access to health care providers who are experienced in treating LGBT individuals.
Although these areas represent critical dimensions of the experiences of LGBT individuals, the relationships of these variables to health care disparities and health status have not been extensively studied.
STATEMENT OF TASK AND STUDY SCOPE
In the context of the issues outlined above, the IOM was asked by the National Institutes of Health (NIH) to convene a Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The 17-member committee included experts from the fields of mental health, biostatistics, clinical medicine, adolescent health and development, aging, parenting, behavioral sciences, HIV research, demography, racial and ethnic disparities, and health services research. The committee's statement of task is shown in Box 1-1. The study was supported entirely by NIH.
Statement of Task. An IOM committee will conduct a review and prepare a report assessing the state of the science on the health status of lesbian, gay, bisexual, and transgender (LGBT) populations; identify research gaps and opportunities related to LGBT (more...)
Although intersexuality constitutes an additional type of “otherness” that is stigmatized and overlaps in some respects with LGBT identities and health issues, the committee decided it would not be appropriate to include intersexuality in the study scope. The majority of individuals affected by disorders of sex development do not face challenges related to sexual orientation and gender identity, although homosexuality, gender role nonconformity, and gender dysphoria (defined as discomfort with the gender assigned to one at birth [see Chapter 2]) are somewhat more prevalent among this population compared with the general population (Cohen-Kettenis and Pfafflin, 2003). The committee acknowledges that while very little research exists on the subject of intersexuality, it is a separate research topic encompassing critical issues, most of which are not related to LGBT issues, and hence is beyond the scope of this report.
In a similar vein, the committee decided not to address research and theory on the origins of sexual orientation. The committee's task was to review the state of science on the health status of LGBT populations, to identify gaps in knowledge, and to outline a research agenda in the area of LGBT health. The committee recognized that a thorough review of research and theory relevant to the factors that shape sexual orientation (including sexual orientation identity, sexual behavior, and sexual desire or attraction) would be a substantial task, one that would be largely distinct from the committee's main focus on LGBT health, and therefore beyond the scope of the committee's charge.
This study was informed by four public meetings that included 35 presentations (see Appendix A). Three of these meetings were held in Washington, DC, while the fourth took place in San Francisco. In addition, the committee conducted an extensive review of the literature using Medline, PsycInfo, and the Social Science Citation Index (see Appendix B for a list of search terms), as well as other resources. The committee's approach to the literature is described below, followed by a discussion of the various frameworks applied in this study. A brief note on the terminology used in this report is presented in Box 1-2.
A Note on Terminology. As discussed, the committee adopted the commonly used shorthand LGBT to stand for lesbian, gay, bisexual, and transgender. In cases in which the literature refers only to lesbian, gay, and bisexual populations, the term LGB appears (more...)
Approach to the Literature
While acknowledging that peer-reviewed journals are the gold standard for the reporting of research results and making every effort to consult works published in major research journals, the committee chose to include in this study what it judged to be the best empirical literature available: journal articles, book chapters, empirical reports, and other data sources that had been critically reviewed by the committee members. Recognizing that academic journals differ in their publication criteria and the rigor of their peer-review process, the committee gave the greatest weight to papers published in the most authoritative journals. Given that chapters, academic books, and technical reports typically are not subjected to the same peer-review standards as journal articles, the committee gave the greatest credence to such sources that reported research employing rigorous methods, were authored by well-established researchers, and were generally consistent with scholarly consensus on the current state of knowledge.
With respect to articles describing current health issues in the LGBT community, the committee attempted to limit its review to these articles published since 1999. In the area of transgender populations, however, much of the most current research was conducted prior to 1999 and is cited throughout the report. Likewise, in the case of history and theory, the committee reviewed and cites older literature.
When evaluating quantitative and qualitative research, the committee considered factors affecting the generalizability of studies, including sample size, sample source, sample composition, recruitment methods, and response rate. The committee also considered the study design, saturation (the point at which new information ceases to emerge), and other relevant factors. In some cases, the committee decided that a study with sample limitations was important; in such cases, these limitations and limits on the extent to which the findings can be generalized are explicitly acknowledged. The inclusion of case studies was kept to a minimum given their limited generalizability.
Research on U.S. samples was given priority. In cases in which no U.S.-based data were available or the committee determined that it was important to include research on non-U.S. samples, however, this research is cited. This was frequently the case for research involving transgender people. Only English-language articles were considered.
The committee considered papers whose authors employed statistical methods for analyzing data, as well as qualitative research that did not include statistical analysis. For papers that included statistical analysis, the committee evaluated whether the analysis was appropriate and conducted properly. For papers reporting qualitative research, the committee evaluated whether the data were appropriately analyzed and interpreted. The committee does not present magnitudes of differences, which should be determined by consulting individual studies.
In some cases, the committee used secondary sources such as reports. However, it always referred back to the original citations to evaluate the evidence.
In understanding the health of LGBT populations, multiple frameworks can be used to examine how multiple identities and structural arrangements intersect to influence health care access, health status, and health outcomes. This section provides an overview of each of the conceptual frameworks used for this study.
First, recognizing that there are a number of ways to present the information contained in this report, the committee found it helpful to apply a life-course perspective. A life-course perspective provides a useful framework for the above-noted varying health needs and experiences of an LGBT individual over the course of his or her life. Central to a life-course framework (Cohler and Hammack, 2007; Elder, 1998) is the notion that the experiences of individuals at every stage of their life inform subsequent experiences, as individuals are constantly revisiting issues encountered at earlier points in the life course. This interrelationship among experiences starts before birth and in fact, before conception. A life-course framework has four key dimensions:
Linked lives—Lives are interdependent; social ties, including immediate family and other relationships, influence individuals' perspective on life.
Life events as part of an overall trajectory—Significant experiences have a differential impact at various stages of the life course.
Personal decisions—Individuals make choices influenced by the social contexts in which they live (e.g., family, peers, neighborhood, work setting).
Historical context—A historical perspective provides a context for understanding the forces and factors that have shaped an individual's experiences; those born within the same historical period may experience events differently from those born earlier or later.
From the perspective of LGBT populations, these four dimensions have particular salience because together they provide a framework for considering a range of issues that shape these individuals' experiences and their health disparities. The committee relied on this framework and on recognized differences in age cohorts, such as those discussed earlier, in presenting information about the health status of LGBT populations.
Along with a life-course framework, the committee drew on the minority stress model (Brooks, 1981; Meyer, 1995, 2003a). While this model was originally developed by Brooks (1981) for lesbians, Meyer (1995) expanded it to include gay men and subsequently applied it to lesbians, gay men, and bisexuals (Meyer, 2003b). This model originates in the premise that sexual minorities, like other minority groups, experience chronic stress arising from their stigmatization. Within the context of an individual's environmental circumstances, Meyer conceptualizes distal and proximal stress processes. A distal process is an objective stressor that does not depend on an individual's perspective. In this model, actual experiences of discrimination and violence (also referred to as enacted stigma) are distal stress processes. Proximal, or subjective, stress processes depend on an individual's perception. They include internalized homophobia (a term referring to an individual's self-directed stigma, reflecting the adoption of society's negative attitudes about homosexuality and the application of them to oneself), perceived stigma (which relates to the expectation that one will be rejected and discriminated against and leads to a state of continuous vigilance that can require considerable energy to maintain; it is also referred to as felt stigma), and concealment of one's sexual orientation or transgender identity. Related to this taxonomy is the categorization of minority stress processes as both external (enacted stigma) and internal (felt stigma, self-stigma) (Herek, 2009; Scambler and Hopkins, 1986).
There is also supporting evidence for the validity of this model for transgender individuals. Some qualitative studies strongly suggest that stigma can negatively affect the mental health of transgender people (Bockting et al., 1998; Nemoto et al., 2003, 2006).
The minority stress model attributes the higher prevalence of anxiety, depression, and substance use found among LGB as compared with heterosexual populations to the additive stress resulting from nonconformity with prevailing sexual orientation and gender norms. The committee's use of this framework is reflected in the discussion of stigma as a common experience for LGBT populations and, in the context of this study, one that affects health.
In addition to the minority stress model, the committee believed it was important to consider the multiple social identities of LGBT individuals, including their identities as members of various racial/ethnic groups, and the intersections of these identities with dimensions of inequality such as poverty. An intersectional perspective is useful because it acknowledges simultaneous dimensions of inequality and focuses on understanding how they are interrelated and how they shape and influence one another. This framework also challenges one to look at the points of cohesion and fracture within racial/ethnic sexual- and gender-minority groups, as well as those between these groups and the dominant group culture (Brooks et al., 2009; Gamson and Moon, 2004).
Intersectionality encompasses a set of foundational claims and organizing principles for understanding social inequality and its relationship to individuals' marginalized status based on such dimensions as race, ethnicity, and social class (Dill and Zambrana, 2009; Weber, 2010). These include the following:
Race is a social construct. The lived experiences of racial/ethnic groups can be understood only in the context of institutionalized patterns of unequal control over the distribution of a society's valued goods and resources.
Understanding the racial and ethnic experiences of sexual- and gender-minority individuals requires taking into account the full range of historical and social experiences both within and between sexual- and gender-minority groups with respect to class, gender, race, ethnicity, and geographical location.
The economic and social positioning of groups within society is associated with institutional practices and policies that contribute to unequal treatment.
The importance of representation—the ways social groups and individuals are viewed and depicted in the society at large and the expectations associated with these depictions—must be acknowledged. These representations are integrally linked to social, structural, political, historical, and geographic factors.
Intersectional approaches are based on the premise that individual and group identities are complex—influenced and shaped not just by race, class, ethnicity, sexuality/sexual orientation, gender, physical disabilities, and national origin but also by the confluence of all of those characteristics. Nevertheless, in a hierarchically organized society, some statuses become more important than others at any given historical moment and in specific geographic locations. Race, ethnicity, class, and community context matter; they are all powerful determinants of access to social capital—the resources that improve educational, economic, and social position in society. Thus, this framework reflects the committee's belief that the health status of LGBT individuals cannot be examined in terms of a one-dimensional sexual- or gender-minority category, but must be seen as shaped by their multiple identities and the simultaneous intersection of many characteristics.
Finally, the social ecology model (McLeroy et al., 1988) draws on earlier work by Bronfenbrenner (1979), which recognizes that influences on individuals can be much broader than the immediate environment. This viewpoint is reflected in Healthy People 2020. In developing objectives to improve the health of all Americans, including LGBT individuals, Healthy People 2020 used an ecological approach that focused on both individual-and population-level determinants of health (HHS, 2000, 2011). With respect to LGBT health in particular, the social ecology model is helpful in conceptualizing that behavior both affects the social environment and, in turn, is affected by it. A social ecological model has multiple levels, each of which influences the individual; beyond the individual, these may include families, relationships, community, and society. It is worth noting that for LGBT people, stigma can and does take place at all of these levels. The committee found this framework useful in thinking about the effects of environment on an individual's health, as well as ways in which to structure health interventions.
Each of the above four frameworks provides conceptual tools that can help increase our understanding of health status, health needs, and health disparities in LGBT populations. Each complements the others to yield a more comprehensive approach to understanding lived experiences and their impact on LGBT health. The life-course perspective focuses on development between and within age cohorts, conceptualized within a historical context. Sexual minority stress theory examines individuals within a social and community context and emphasizes the impact of stigma on lived experiences. Intersectionality brings attention to the importance of multiple stigmatized identities (race, ethnicity, and low socioeconomic status) and to the ways in which these factors adversely affect health. The social ecology perspective emphasizes the influences on individuals' lives, including social ties and societal factors, and how these influences affect health. The chapters that follow draw on all these conceptualizations in an effort to provide a comprehensive overview of what is known, as well as to identify the knowledge gaps.
This report is organized into seven chapters. Chapter 2 provides context for understanding LGBT health status by defining sexual orientation and gender identity, highlighting historical events that are pertinent to LGBT health, providing a demographic overview of LGBT people in the United States, examining barriers to their care, and using the example of HIV/AIDS to illustrate some important themes. Chapter 3 addresses the topic of conducting research on the health of LGBT people. Specifically, it reviews the major challenges associated with the conduct of research with LGBT populations, presents some commonly used research methods, provides information about available data sources, and comments on best practices for conducting research on the health of LGBT people.
As noted, in preparing this report, the committee found it helpful to discuss health issues within a life-course framework. Chapters 4, 5, and 6 review, respectively, what is known about the current health status of LGBT populations through the life course, divided into childhood/adolescence, early/middle adulthood, and later adulthood. Each of these chapters addresses the following by age cohort: the development of sexual orientation and gender identity, mental and physical health status, risk and protective factors, health services, and contextual influences affecting LGBT health. Chapter 7 reviews the gaps in research on LGBT health, outlines a research agenda, and offers recommendations based on the committee's findings.
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This latter phrase carries quotation marks because it is drawn from the preamble to the Constitution of the World Health Organization (WHO, 1946), which defines health broadly, and appropriately, as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” For the purposes of this report, the committee defines “health” broadly in accordance with this definition. Therefore, health encompasses multiple dimensions including physical, emotional, and social well-being and quality of life.