with 6.9 percent of women born after 1969. The authors note that the increased prevalence of women reporting same-sex contact coincides with an increase in societal tolerance of same-sex sexual activity, although it is not clear whether the two phenomena are linked. A comparable pattern was not evident among men, although men’s self-reports of same-sex behavior increased somewhat during the 1990s.

BARRIERS TO ACCESSING HEALTH CARE

Sexual and gender minorities face a number of barriers to accessing health care, many of which can be traced to stigma and its consequences. Multiple components of stigma influence the health and well-being of sexual and gender minorities. This section defines the components of stigma, reviews barriers to accessing health care for members of LGBT populations, and describes how the cross-cutting theme of stigma is associated with these barriers at both the personal and structural levels.

Stigma

As used in this report, the term stigma refers to the inferior status, negative regard, and relative powerlessness that society collectively assigns to individuals and groups that are associated with various conditions, statuses, and attributes (Goffman, 1963; Herek, 2009a; Link and Phelan, 2001). Social scientists have long recognized that stigma is not inherent in a particular trait or in membership in a particular group. Rather, society collectively identifies and assigns negative meaning and value to certain characteristics and groups, thereby “constructing” stigma. Thus, in perhaps the best known theoretical analysis of the concept, Erving Goffman (1963, p. 5) characterized stigma as “an undesired differentness.” Sexual stigma refers specifically to the stigma attached to any nonheterosexual behavior, identity, relationship, or community (e.g., Herek, 2009a). Transgender stigma is used here to refer to the stigma attached to individuals who self-identify as transgender or transsexual or whose gender expression or comportment varies from societal gender norms.

Access and Barriers to Care

The Institute of Medicine (IOM) defines access to health care as the “timely use of personal health services to achieve the best possible outcomes” (IOM, 1993, p. 4). Drawing on the social ecology model, the committee categorized barriers to accessing high-quality care as both personal and structural. LGBT individuals face both types of barriers. Although many of these barriers can be traced to sexual and transgender



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