Those belonging to the current cohort of adults would have witnessed the genesis of the gay rights movement during their childhood. They would have experienced the explosion of the HIV/AIDS epidemic as they transitioned into adulthood, and as adults they would have seen the U.S. Supreme Court strike down all sodomy laws in Lawrence v. Texas in 2003 and, in 2004, Massachusetts become the first state to legalize marriage between same-sex couples.
Early/middle adulthood, defined roughly in this report as the period of life from the 20s to the 60s, is ushered in by a transition from adolescence generally thought to involve a number of physiological, work, family, and social life milestones. These include the physical changes associated with puberty and growth in adulthood, as well as the completion of formal education, issues of career choice and efforts to establish financial independence, the selection of a mate (often with the introduction of children into the relationship), the launching of friendships and other interpersonal relationships, and community involvement. During the adult years, these physiological, work, family, and social life domains continue to evolve. The journey through adulthood is often characterized by the physical manifestations of midlife, career achievements and transitions, relationship and family development and changes, and changes in interpersonal ties and community participation. These same domains and issues characterize the experiences of LGBT adults, albeit often in different forms. People who are LGBT engage in educational and career pursuits in ways that are similar to those of their heterosexual peers (even if levels and outcomes may differ). Other domains, however, particularly marriage and parenthood, may be
affected by larger cultural and legal forces. Personal relationships, social support, and community involvement may also assume different forms, similarly affected by cultural influences.
The last two decades have seen a growing recognition of the unique health needs of LGBT individuals. Research, however, is still sparse on the developmental life stage of adulthood with regard to the specific health issues confronted by the LGBT community broken down by race/ethnicity and socioeconomic status, with the largest body of work focusing on HIV/ AIDS.
The following sections describe research on LGBT adults in the areas of the development of sexual orientation and gender identity; mental health status; physical health status; risk and protective factors; health services; and contextual influences, including demographic characteristics and the role of the family. The final section presents a summary of key findings and research opportunities. It is important to note that some of the literature presented in this chapter may also appear in the following chapter on later adulthood because studies do not always delineate their findings according to the age ranges used in this report, and certain studies may present findings that are relevant to both early/middle and later adulthood.
DEVELOPMENT OF SEXUAL ORIENTATION AND GENDER IDENTITY
The process of sexual orientation development and of “coming out” is different for each LGBT individual. As individuals come out, they reach various milestones in the process: they experience their first awareness of same-sex attraction, they have their first same-sex sexual experience, they self-identify as LGB, and they choose to disclose their sexual orientation identity to others. Depending on contextual factors in their lives, LGB individuals may choose to come out at many different times throughout the life course, and the stage at which they come out will influence their experiences. Moreover, the association between sexual orientation identity, or coming out, and mental health is not invariant across LGBT populations in the United States. Multiple social, cultural, and psychological influences affect the extent to which members of homosexually active populations experience favorable consequences from self-identity as lesbian or gay. Thus, the assumption of a universal positive link between coming out and mental health appears unwarranted.
Gates (2010) examined the relationship between demographic factors and coming out among different age cohorts using data from the 2008 General Social Survey, a nationally representative sample of 2,023 adults aged 18 and older. Of the 1,773 respondents providing information about sexual orientation and behavior, 58 self-identified as LGB, and 104 reported
same-sex partners. The authors found that relative to individuals younger than 30, adults aged 30–54 were 16 times more likely to be closeted
In their analysis of a nonprobability sample of 2,001 women (mean age = 40) who self-identified as lesbian or bisexual or reported sexual activity with or attraction to other women, Corliss and colleagues (2009) found that on average, the women reported first awareness of same-sex sexual attractions at age 16, first coming out to another person at age 23, and first sexual encounter with another woman at age 21. They also found that women who were aware of their same-sex attractions before age 12 were more likely to be Latina or black, more likely to come from families with less parental education, and more likely to self-identify as a lesbian than as a bisexual woman. Those who reported coming out and having a sexual experience with another female before age 18 were more likely to be younger and less educated than other women in the sample.
Factors such as race, ethnicity, and education may affect the coming-out process differently for nonwhite and white members of sexual minorities in the United States. In a review of the effects of social context on black homosexual males, Peterson and Jones (2009) note that studies reveal that, relative to men of other racial groups, black men experience higher levels of internalized homophobia, are less likely to disclose their homosexual orientation, and are more likely to perceive that their friends and neighbors disapprove of homosexuality. While the effects of race, ethnicity, and education may be widespread, they are likely even more salient among low-income than middle-class nonwhite LGB individuals. Moreover, the resources and social support typically received by nonwhite LGBT individuals from their racial/ethnic communities before they come out may often be jeopardized if they come out, and this may create significant barriers to the coming out process for these individuals. In addition, black LGBT individuals may experience racism in mainstream gay and lesbian communities. In a survey of 2,645 LGBT individuals at “black gay pride” festivals across the United States, nearly half of the participants believed that racism was a problem within primarily white LGBT communities. Such experiences pose further obstacles to coming out for these individuals (Battle et al., 2002).
For LGB individuals who come out during adulthood, factors such as marital status and parenthood may also influence the coming out process. For example, Morris and colleagues (2002) compared developmental milestones among 2,431 self-identified lesbians and bisexual women who had children before coming out (n = 313, mean age = 44.8) or after coming out (n = 187, mean age = 39.7) or did not have children (n = 1,919, mean age = 34.6). They found that mothers who had children before coming out reached developmental milestones at older ages than both other groups. Mothers who had children before coming out reached each milestone in the coming out process approximately 7 to 12 years later than mothers
who had children after coming out and approximately 6 to 8 years later than nonmothers.
As society continues to change, the timing of coming out and achieving developmental milestones also changes. In 1994 Drasin and colleagues (2008) published a survey in The Advocate and examined data from 2,402 self-identified gay men aged 18–83 (mean age = 38.3) to determine whether trends in developmental, psychological, and sexual developmental milestones differed by age cohort and whether those trends had changed over time. Recognizing that this sample may have omitted younger men who identify as gay later in life and that readers of The Advocate may be more likely to identify as gay, the authors performed conservative sensitivity tests on the data and made conservative corrections accordingly. They found that of those who were aged 50 or older at the time of the survey (16 percent of the sample), 57 percent had realized they were gay by age 18, 22 percent had done so by age 22, and 9 percent had not done so by age 30. In examining the social, sexual, and psychological milestones for their sample, the authors found that the milestones occurred at an earlier age in younger cohorts, but the changes in age at occurrence by cohort are occurring at different rates. For instance, while sexual behavior milestones (age at first sexual contact with another male) are changing slowly, individual psychological milestones (age at first awareness of same-sex attraction, self-identification as gay) are changing more rapidly, and social milestones (age at first coming out, frequenting a gay bar) are changing even more rapidly. Even with the corrections performed by the authors, results showed that coming out to a family member has changed from occurring at age 40 among those who reached age 18 before 1953, to the mid-30s for those who reached age 18 between 1953 and 1962, to the mid- to late 20s in the 1963 to 1982 cohort, to around age 21 for those who reached 18 after 1982.
The existing literature examines some of the factors that influence the timing of the coming out process among LGB adults. Further research is needed to elucidate the ways in which the timing of the coming out process influences the health status of LGB people and their specific health needs.
Transgender individuals are coming out to affirm their gender identity at younger and younger ages (Makadon et al., 2007). Transgender men tend to come out at earlier ages than transgender women (Zucker and Lawrence, 2009). Transgender women can generally be divided into two groups: those who have been gender nonconforming since childhood in both role and identity and those who have been gender conforming in role, but may or may not have been aware of feelings of cross-gender identity in childhood or adolescence (Bockting and Coleman, 2007; Lawrence, 2010). The latter individuals typically report cross-dressing in private, which initially is often accompanied by sexual arousal; their feelings of cross-gender identity may be expressed in sexual fantasy (Bockting and Coleman, 2007),
particularly among older-generation white transgender women (Nuttbrock et al., 2009a). Transgender women who did not conform to gender roles in childhood tend to come out at an early age, either before or during early adulthood, and if so desired, change gender roles and feminize their body through hormone therapy and/or surgery (Bockting and Coleman, 2007; Lawrence, 2010). By contrast, transgender women who were gender role conforming in childhood tend to come out during mid- or later life (Bockting and Coleman, 2007; Lawrence, 2010), and their developmental challenges may vary as a result. Whereas gender role–nonconforming individuals must develop resilience in the face of enacted stigma early in life (Nuttbrock et al., 2010), gender role–conforming individuals may protect themselves against enacted stigma by keeping their transgender feelings private, yet are likely to experience felt stigma and, in isolation, may not benefit from the support a community of similar others can provide (Meyer, 2007).
Several authors have attempted to describe the process of transgender identity development or to adapt stage models of gay and lesbian coming out (Minton and McDonald, 1983) to the coming out process of transgender individuals. Bockting and Coleman (2007) describe five stages (pre-coming out, coming out, exploration, intimacy, and identity integration) based on Erikson’s (1950) model of social development and their extensive clinical experience in working with transgender individuals. Devor (2004) defines 14 possible stages of transgender identity development based on sociological field research and in-depth interviews with transgender men. Gagne and colleagues (1997) define four stages (early transgender experiences, coming out to one’s self, coming out to others, and resolution of identity) based on a qualitative study of transgender women. Lewins (1995) describes six stages of becoming a (transgender) woman (abiding anxiety, discovery, purging and delay, acceptance, surgical reassignment, and invisibility) based on interviews with transsexual women. Finally, based on her clinical experience and a review of the scientific literature, Lev (2004) describes six stages of transgender emergence: awareness; seeking information/reaching out; disclosure to significant others; exploration, identity, and self-labeling; exploration, transition issues, and possible body modification; and integration, acceptance, and posttransition issues. Although informed by formative research, these stage models have not been tested empirically and systematically.
MENTAL HEALTH STATUS
LGBT adults are typically well adjusted and mentally healthy. Studies based on probability samples of LGB populations indicate that the majority of LGB adults do not report mental health problems (Cochran and Mays,
2006; Herek and Garnets, 2007). While national probability samples of transgender adults are not available, data from convenience samples similarly show that many, if not most, transgender adults do not report mental health problems (Clements-Nolle et al., 2001; Nuttbrock et al., 2010).
Nonetheless, disparities in mental health do exist among some sexual-minority groups. In a meta-analysis of research on mental health among LGB people published between 1966 and 2005, King and colleagues (2008) examined the prevalence of a number of mental health outcomes. They found that LGB individuals had a 1.5 times higher risk for depression and anxiety disorders over a period of 12 months or a lifetime than heterosexual individuals. Other findings revealed that the risk for suicide attempts over a lifetime among lesbian, gay, and bisexual individuals was more than twice as great as that among heterosexual individuals.
The evidence is not conclusive, however. A study comparing lesbians and their heterosexual sisters as a control group found no difference in the prevalence of mental health problems between the lesbian–heterosexual sister pairs (n = 184 pairs), but found that the lesbians had significantly higher self-esteem than their heterosexual sisters (Rothblum and Factor, 2001). Horowitz and colleagues (2003) examined specific quality-of-life indicators by behaviorally defined sexual orientation categories (heterosexual, homosexual, bisexual since age 18 and within the last 12 months) (n = 11,536). They found that there were no significant differences among heterosexual, homosexual, and bisexual men and women with respect to general happiness, perceived health, or job satisfaction since age 18 or within the last 12 months.
For transgender people, the available studies generally suggest high rates of negative mental health outcomes. Most of these studies, however, are limited by the use of nonprobability samples, and few compare the mental health of transgender people and nontransgender controls. A clinical sample of 31 male-to-females reported significantly more symptoms on the General Severity Index (GSI) of the Brief Symptom Inventory relative to nontransgender men (n = 57). Further analyses of the data indicated clinically significant levels of anxiety and depression, along with increased feelings of self-consciousness and distrust of other people (Derogatis et al., 1978). A clinical sample of 20 female-to-males showed no clinically significant differences on the GSI in comparison with nontransgender females (n = 143); however, scores on subscales of anxiety and interpersonal sensitivity were elevated (Derogatis et al., 1981). There also appear to be mental health differences among lesbian, gay, bisexual, and transgender populations. For instance, in a chart review of 223 lesbians and bisexual women presenting to a mental health clinic, Rogers and colleagues (2003) found that the lesbians were more likely than the bisexual women to present at intake with suicidal ideation, while the bisexual women were more likely to
present with stressors related to social environment and health care access. Similarly, Page (2004) explored the experiences with mental health services of self-identified bisexual men and women (n = 217) and found that the bisexual men had experienced greater stress related to their bisexual identity and that bisexual issues had played a more significant role in their decision to seek mental health services. Mathy (2002a,b) compared the mental health status of 73 transgender individuals and nonclinical samples of nontransgender women and men, either homosexual or heterosexual. The transgender individuals were more likely to report suicidal ideation and attempts, to take psychotropic medications, and to have a problem with alcohol relative to the nontransgender men and heterosexual women, but no such differences were found between the transgender and lesbian individuals. For the latter two groups, the author attributed the higher likelihood of mental health and substance use problems to their experiencing both heterosexism and sexism. Bockting and colleagues (Bockting et al., 2005a) compared baseline data from an intervention study of 207 transgender participants, 480 men who have sex with men, and 122 bisexually active women; the transgender individuals were most likely to report depression (52 percent versus 38 percent and 40 percent, respectively) and suicidal ideation (47 percent versus 31 percent and 32 percent, respectively). However, this study did not assess depression with a standardized instrument.
While more research has been conducted on mental health than on physical health conditions among LGBT adults, large gaps still remain in our understanding of mental health issues among LGBT people. There is conflicting evidence on the mental health status of LGB adults, and the existing research examining the mental health of transgender adults has limitations. It is clear, however, that deleterious effects on the mental health of lesbian, gay, and bisexual individuals result overwhelmingly from unique, chronic stressors due to the stigma they experience as a disadvantaged minority in American society (Meyer, 2003). Herek and Garnets (2007) note that sexual stigma leads to stress resulting from multiple types of “enacted stigma” (e.g., personal rejection and ostracism, discrimination, and criminal victimization), which can have serious and enduring psychological consequences. Beyond such direct manifestations of stigma, Herek and Garnets (2007) suggest there are pervasive effects of institutionalized stigma, or “heterosexism,” among gay, lesbian, and bisexual populations, such as denial of the right to marriage in most states, negative economic effects in the workplace, and frequent disenfranchisement from religious and spiritual resources needed to ameliorate the effects of stress.
Herek and Garnets (2007) also identify two other sources of stress experienced by sexual minorities: “felt stigma” and “self-stigma.” They contend that felt stigma—the subjective experience of stigma against one’s group, even without direct experience of enacted stigma—may often occur
as a consequence of societal events in which antigay hostility is demonstrated (e.g., antigay violence, antigay political campaigns). Likewise, these authors suggest that self-stigma may occur among some sexual minorities as a result of accepting society’s negative attitudes toward them (e.g., internalized homophobia, internalized heterosexism, and internalized homonegativity). These negative feelings about one’s own homosexual desires can have negative impacts on mental and physical health and heighten the stress experienced by sexual minorities.
Some population studies have compared rates of anxiety disorders in homosexually and heterosexually active men and women. Using data from the 1996 National Household Survey of Drug Abuse, Cochran and Mays (2000b) examined differences in the prevalence of psychiatric syndromes among sexually active individuals. Behavioral sexual orientation was compared between respondents who reported exclusively other-sex sex partners (n = 9,714) and those who reported any same-sex sex partners (n = 194) in the prior year. While most homosexually active individuals did not meet criteria for any of the syndromes assessed, multivariate logistic regression analyses revealed that homosexually active men were more likely than other men to evidence a panic attack syndrome.
Cochran and Mays (2000a) also examined possible associations between homosexual/bisexual behavior patterns and lifetime prevalence of affective disorders, including mania, major depression, and dysthymia, among men (aged 17–39) using data from the National Health and Nutrition Examination Survey (NHANES) III. Sexual orientation was defined behaviorally based on self-reports of sexual partners and classified into three groups: any male sex partners (n = 108), only female partners (n = 3,208), and no sexual partners (n = 187). The results revealed that homosexually/ bisexually experienced men were no more likely than exclusively heterosexual men to meet criteria for lifetime diagnoses of affective disorders.
Similarly, Gilman and colleagues (2001) examined the risk of psychiatric disorders among individuals with same-sex and different-sex sexual partners based on data from the National Comorbidity Survey. Respondents were asked two sexual behavior questions: the number of women and, separately, men with whom they had engaged in sexual intercourse in the prior 5 years. Based on these responses, the respondents were classified into three groups: any same-sex partners (n = 125), exclusively heterosexual partners (n = 4,785), and no sexual partners (n = 967). Respondents with same-sex sexual partners had a higher 12-month prevalence of anxiety and mood disorders than respondents with different-sex partners only. The authors note the limitation that using a behavioral definition of
sexual orientation excludes those respondents not sexually active in the 5 years prior to the interview.
Cochran and colleagues (2003) later analyzed data from the MacArthur Foundation National Survey of Midlife Development in the United States (MIDUS) to examine possible sexual orientation–related differences in morbidity, distress, and use of mental health services. The sexual orientation of 2,917 adults (aged 25–74) was based on self-report as heterosexual (n = 2,844), homosexual (n = 41), or bisexual (n = 32). The samples of individuals who identified as homosexual and those who identified as bisexual were combined for analysis. The results revealed that gay/bisexual men had a higher prevalence of panic attacks than heterosexual men, while lesbian/ bisexual women had a higher prevalence of generalized anxiety disorder than heterosexual women. However, the authors note the limited number of participants who reported a homosexual or bisexual orientation.
More recently, Bostwick and colleagues (2010) used data from the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions (n = 34,653) to examine lifetime and past-year mood and anxiety disorders among different sexual orientation groups. Identity, attraction, and behavior measures were used to assess sexual orientation. The authors found mental health disparities among some sexual-minority groups. Self-identified lesbian, gay, or bisexual individuals had higher rates of mood and anxiety disorders than self-identified heterosexual individuals. Women who reported exclusively same-sex sexual behavior and women who reported exclusively same-sex attraction were found to have some of the lowest rates of mood and anxiety disorders. With the exception of these women, however, individuals reporting any same-sex sexual behavior or same-sex attraction were found to have higher rates of most mood and anxiety disorders than those reporting exclusively different-sex sexual behavior or exclusively different-sex attraction. Bisexual behavior was found to be associated with the highest incidence of mood or anxiety disorders.
There have been relatively few studies on the prevalence of mood and anxiety disorders among transgender adults. In a study previously mentioned, Derogatis and colleagues (1978) found significantly higher levels of anxiety and depression among a sample of male-to-female transsexuals in comparison with nontransgender men. More recent literature on depression among transgender adults is presented in the next section.
Some evidence is available from population studies on differences in rates of major depression between homosexually and heterosexually active men and women. Cochran and Mays (2000b) examined possible differences in psychiatric syndromes between homosexually active and heterosexually
active men and women using data from the National Household Survey of Drug Abuse. Men who have sex with men were more likely than exclusively heterosexual men to be diagnosed with major depression. Homosexually active women were no more likely than exclusively heterosexual women to evidence major depression syndrome.
Cochran and colleagues (2003), using data from the MIDUS survey, found that the sample of self-identified gay and bisexual men (combined for analysis) showed a higher prevalence of depression than heterosexual men. Gilman and colleagues (2001), using data from the National Comorbidity Survey, found that women with any same-sex partner had a significantly higher 12-month prevalence of major depression than women with only different-sex partners. Conron and colleagues (2008), using data from the Massachusetts Behavioral Risk Factor Surveillance System survey of adults aged 18–64 (n = 38,910), found that bisexual adults were significantly more likely to report feeling “sad or blue” than either heterosexual or lesbian and gay adults.
Cochran and colleagues (2007c) also looked at differences in mental health disorders using data from the National Latino and Asian American Study (n = 4,488). Sexual orientation was defined based on self-identity and past-year history of sexual experiences. Those who identified as gay, lesbian, or bisexual and/or reported any same-sex sexual experiences in the past year (n = 245) were compared with the rest of the sample. Results showed that lesbian/bisexual women were significantly more likely than heterosexual women to meet criteria for depressive disorders, either in the past year or in lifetime histories. Similarly, gay/bisexual men were significantly more likely than heterosexual men to report a recent suicide attempt. The authors note that the prevalence of mental health disorders found in sexual-minority Latinos and Asian Americans was similar to or lower than that found in population-based studies of lesbian, gay, and bisexual adults in general.
Rates of depression among transgender people are far less well studied. In a convenience sample of 392 transgender women and 123 transgender men aged 18–67 in San Francisco, rates of depression ranged from 5 percent among transgender men to 62 percent among transgender women (Clements-Nolle et al., 2001). Among LGBT participants in a sexual health seminar intervention, 52 percent of transgender participants (n = 207) reported depression. This was a higher percentage than that among men who have sex with men (n = 480, 38 percent) or bisexually active women (n = 122, 40 percent) (Bockting et al., 2005a). In their meta-analysis of 29 transgender studies, Herbst and colleagues (2008) found that a large percentage (weighted mean 43.9 percent) of transgender respondents indicated a desire for mental health counseling to address transgender-specific issues.
Some studies have found that nonheterosexual adults are more likely than heterosexual adults to report past suicidal ideation and attempts. Cochran and Mays (2000a), using data from a national probability sample of 3,503 participants (NHANES III), found that men who reported same-sex sexual behavior showed greater lifetime prevalence rates of suicidal ideation and suicide attempts than men who reported exclusively different-sex sexual behavior, even after adjustment for possible demographic confounding.
Using data from the National Comorbidity Survey in a study previously described, Gilman and colleagues (2001) observed differences in suicide symptoms between men and women participants with same-sex (n = 125) and different-sex (n = 4,785) sexual partners. They found no significant differences in the 12-month prevalence of suicidal thoughts, plans, and attempts between those with same-sex and different-sex partners overall. Among women, however, they found a higher prevalence of suicidal thoughts and plans in the any same-sex partner group than in the other-sex partner group, and among men, a higher prevalence of suicidal plans and attempts in the any same-sex partner group than in the other-sex partner group. Also, the lifetime risk of suicidal thoughts was significantly greater for both men and women in the same-sex partner group than in the different-sex partner group. Overall, the authors note that the effects of having same-sex versus different-sex partners appear to be stronger for women than for men.
Other studies have demonstrated that suicidal ideation and behavior vary by both sexual orientation and gender. Mathy and colleagues (2003) compared suicidal intent, mental health difficulties, and mental health treatment among bisexual and transgender individuals. They found that, relative to bisexual males (n = 1,457), bisexual females (n = 792) and transgender individuals (n = 73) had a higher prevalence of all three variables (Mathy et al., 2003). In a study of 1,304 women conducted at 33 health care sites across the United States, Koh and Ross (2006) found that differences in rates of suicidal ideation and attempts varied among bisexual women (n = 143), lesbians (n = 524), and heterosexual women (n = 637) and were also correlated with disclosure of sexual orientation. Bisexual women who had disclosed their sexual orientation to a majority of friends, family, and coworkers were twice as likely to have reported suicidal ideation relative to heterosexual women. Among sexual minorities who had not disclosed their sexual orientation to a majority of friends, family, and coworkers, lesbians were 90 percent more likely to have ever made a suicide attempt, and bisexual women were three times more likely than heterosexual women to have done so (Koh and Ross, 2006).
One study, based on a convenience sample, suggests that rates of suicide attempts vary by age among sexual minorities. In a sample of New York City lesbian, gay, and bisexual persons aged 18–59 (n = 388) recruited through direct solicitation and snowball techniques in a variety of venues, Meyer and colleagues (2008) found that 15.6 percent of those aged 45–59 had made a serious suicide attempt, a higher percentage than that among those aged 18–29 or 30–44.
Other studies have found a relationship between race and suicide attempts. In a study of 388 black, white, and Latina/o lesbians, gay men, and bisexual individuals, Meyer and colleagues (2008) found that Latina/o sexual minorities reported a greater number of lifetime suicide attempts than white sexual minorities. Another study examined the lifetime prevalence of suicide attempts among men who have sex with men (n = 2,881) and found that the prevalence was higher among Native American respondents than among respondents reporting other racial/ethnic identities (Paul et al., 2002).
In a unique matched-control study, Herrell and colleagues (1999) provide evidence on suicidality from the Vietnam Era Twin Registry of 4,774 male–male twin pairs who responded to a mail and telephone surve. Most (103) of the 120 middle-aged twins in the analytical study sample who reported same-sex sexual behavior after age 18 had a twin who did not report such behavior. As defined by sexual behavior, same-sex sexual orientation was significantly associated with lifetime suicidal ideation and attempted suicide, even after adjustment for substance use and other depressive symptoms. However, the authors note limitations of the study due to their sampling design and selection criteria.
Other evidence on suicidal symptoms is available from a convenience sample of self-identified lesbian, gay, and bisexual individuals and their siblings (Balsam et al., 2005). The sample included 533 heterosexual, 558 lesbian or gay, and 163 bisexual participants who were compared on suicidal ideation and suicide attempts. Compared with heterosexuals, sexual minorities had a higher prevalence of suicidal ideation and suicide attempts, even after controlling for sibling variance. The authors also hypothesized that bisexual individuals would exhibit greater psychological distress than lesbians and gay men, but the results of their study did not support this hypothesis. Bisexual individuals reported engaging in more self-injurious behavior than lesbians and gay men, but did not have higher rates of suicidal ideation and suicidal attempts. The authors raise the caveat of their convenience sampling despite the possible benefits of their yoked sibling design.
Using convenience samples of the transgender population, researchers have found consistently high rates of suicidal ideation and attempts. In a sample of 392 transgender women and 123 transgender men in San Francisco, Clements-Nolle and colleagues (2001) found that 32 percent
had attempted suicide; Mathy (2002b) found 37 percent ideation and 23 percent attempts among 73 North American self-identified transgender visitors to the MSNBC website; and among 248 transgender people of color in Washington, DC, 38 percent reported suicidal ideation during their lifetime (Xavier et al., 2005). The authors of the latter study further note that in their sample, transgender men were more likely than transgender women to report suicidal ideation (52 percent versus 33 percent), but transgender women were more likely than transgender men to attribute their suicidal ideation to their gender issues (79 percent versus 36 percent). Black participants were least likely of all racial/ethnic groups to report suicidal ideation (Xavier et al., 2005). In a study mentioned earlier involving participants in a sexual health seminar intervention, 47 percent of transgender persons reported suicidal ideation or attempts in the last 3 years, compared with 31 percent of men who have sex with men and 32 percent of behaviorally bisexual women (Bockting et al., 2005a).
Kenagy (2005b) reports on two surveys of 182 transgender adults ranging in age from 17 to 68 (with a mean age of 32). These respondents, primarily from the Philadelphia area, were recruited through snowball sampling and through organizations providing services to transgender persons. Black respondents made up more than 40 percent of the sample, representing the largest racial category, and more than 60 percent of the sample was male to female. Kenagy found that more than 30 percent of the respondents answered that they had “ever attempted suicide.” Subsequent questions about these attempts focused on whether being transgender was a factor; the majority (more than 60 percent) responded affirmatively. A survey of 350 transgender adults in Virginia, ranging in age from 18 to over 65, recruited through service providers, support groups, and informal peer networks, found comparable results (Xavier et al., 2007).
Nuttbrock and colleagues (2010) conducted Life Chart Interviews with a convenience sample of 517 transgender women in New York City and compared data from younger (aged 19–39) and older (aged 40–59) participants. For the younger group, the lifetime prevalence of depression, suicidal ideation, and attempts was 54.7 percent, 53 percent, and 31.2 percent, respectively. For the older group, the corresponding figures were 52.4 percent, 53.5 percent, and 28 percent. Respondents were also asked to report on past symptoms of depression and suicidal ideation at five different stages of their life course. For the younger group, the authors found a significant decline in the prevalence of depression from earlier to later stages of the life course. While 38.4 percent had evidenced depression during ages 10–14, 19.1 percent had done so during ages 30–39. A similar trend was observed for suicide attempts, with 15.6 percent reporting an attempt during ages 10–14 and 8.7 percent reporting an attempt during ages 30–39. Of interest, for the older group, the prevalence of depression remained relatively
constant through the life course: 23.5 percent evidenced depression during ages 10–14, 24.8 percent during ages 30–39, and 26 percent during ages 40–49. The authors interpret this difference between older and younger respondents as an indication of generational differences in adaptation due to the increased visibility of transgender identity.
Eating Disorders/Body Image
Some research, using small samples, suggests that sexual-minority status may be a risk factor for eating disorders among men. Far less research has been conducted among lesbians and bisexual women to determine whether there is an association—either positive or negative—between sexual orientation and eating disorders or body image.
Russell and Keel (2002), for example, conducted a study to examine eating disorders in a convenience sample (n = 122) of gay and heterosexual men, based on their self-identified sexual orientation and sexual behavior (past 2 years); bisexual men were excluded. They observed higher levels of body dissatisfaction and bulimic and anorexic symptoms in gay compared with heterosexual men, even after controlling for depression, self-esteem, and comfort with sexual orientation. Kaminski and colleagues (2005) examined body image in a convenience sample (n = 50) of self-identified gay and heterosexual men. They found that, compared with the heterosexual men, the gay men were more dissatisfied with their bodies even though they were no more likely to be heavier than their perceived ideal weight. In an earlier study, Beren and colleagues (1996) examined differences in body dissatisfaction in a convenience sample (n = 257) of lesbian, gay, and heterosexual adults. Sexual orientation was based on self-reports of attraction to the same or other sex. The authors found that, compared with heterosexual men, gay men reported more body dissatisfaction, even though they were not significantly further from their body ideal. No significant difference was found in body dissatisfaction between lesbians and heterosexual women. Feldman and Meyer (2007b) compared the prevalence of eating disorders in a venue-based sample of 126 white heterosexuals and 388 white, black, and Latino LGB men and women and found that, compared with the heterosexual men, the gay and bisexual men had a higher lifetime prevalence of such disorders. The authors did not find a significant difference in the lifetime prevalence of eating disorders among lesbians and heterosexual and bisexual women. In the previously mentioned study by Koh and Ross (2006), the authors found that bisexual women were more than twice as likely to have had an eating disorder than lesbians. If a bisexual woman reported that she was out, she was twice as likely to have had an eating disorder than a heterosexual woman. These studies demonstrate that further
research is needed to elucidate the relationship between sexual orientation and eating disorders.
Transgender-Specific Mental Health Status
To alleviate gender dysphoria, some transgender individuals change gender roles (either part time or full time), take feminizing or masculinizing hormones, or have surgery (breast/chest, facial, or genital reconstructive surgery). The aim of these interventions is to affirm gender identity and find a gender role and expression that are consistent with that identity.
The clinical management of gender dysphoria has been guided largely by the Standards of Care for Gender Identity Disorders set forth by the World Professional Association for Transgender Health, now in its sixth revision (Meyer et al., 2001). Within the context of a holistic, flexible approach to helping individuals explore their identity and make informed decisions about available treatment options, the Standards of Care include minimal criteria for access to medical interventions to alleviate dysphoria. For adults, these include the following:
For hormone therapy—Evaluation and recommendation by a mental health professional with competency in the assessment and treatment of sexual and gender identity disorders; a period of psychotherapy of a duration specified by the mental health professional (usually a minimum of 3 months) or 3 months of living full time in the preferred gender role (referred to as real life experience); and demonstrable knowledge of what hormones medically can or cannot do and their social benefits and risks.
For breast/chest surgery—For female-to-males, the criteria are the same as for hormone therapy. For male-to-females desiring breast surgery, there is an additional requirement for documentation by both the physician prescribing hormones and the surgeon. The documentation must confirm that after undergoing at least 18 months of hormone therapy, the patient has not achieved sufficient breast enlargement to alleviate dysphoria.
For genital reconstructive surgery—Evaluation and recommendation by two mental health professionals with competency in the assessment and treatment of sexual and gender identity disorders; 12 months of continuous hormone therapy (if applicable); 12 months of living full time in the preferred gender role (referred to as real life experience); if required by the mental health professional, regular participation in psychotherapy; demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and
postsurgical rehabilitation requirements of various surgical approaches; and awareness of different competent surgeons.
The Standards of Care are based on the best available scientific knowledge and clinical consensus among professionals specializing in the assessment and treatment of gender dysphoria, although a rigorous empirical evaluation of the criteria has not been conducted. Nonetheless, the standards have been criticized by transgender community members with respect to the stigmatizing effect of a diagnosis of gender identity disorder, whether psychotherapy should be required before hormone therapy or surgery, whether a period of real life experience before hormone therapy is helpful or potentially harmful, and the value and length of the real life experience before surgery (see Bockting et al., 2009b, for a critical review). Indeed, hormone use (and to a lesser extent surgery) without adherence to the Standards of Care is not uncommon; reports of illicit hormone use in needs assessment studies range from 29 to 71 percent (Clements-Nolle et al., 1999; Nemoto et al., 2005; Xavier, 2000). In addition, a growing number of health providers with varying levels of competence in transgender-specific health care may prescribe hormones and provide access to surgery while making exceptions to or altogether ignoring the Standards of Care (Dean et al., 2000; Lombardi, 2001).
In recent years, alternative approaches have been formalized in written guidelines and protocols by individual community-based health care centers (Callen-Lorde Community Health Center, 2004; Howard Brown Health Center, 2010; Tom Waddell Health Center, 2006). These approaches, characterized as the “informed consent model,” respond to the common criticism of the requirement in the Standards of Care for a mental health provider’s evaluation and recommendation for hormone therapy. Instead, under the “informed consent model,” the first contact is typically with a medical provider, followed by an appointment with an advocate to review one’s transition plan or a psychosocial assessment, education, and counseling (as opposed to the other way around as is the case in the Standards of Care). This approach is aimed at giving transgender individuals greater autonomy in making their own, fully informed health care decision and allows for greater latitude in providing harm-reduction care. The feasibility, acceptability, and effectiveness of this alternative approach have not been systematically evaluated, however.
Only one published study has specifically attempted to evaluate whether adherence to the eligibility criteria of the Standards of Care predicted post-operative satisfaction (Lawrence, 2003). Of 232 male-to-female transsexuals, 51 (22 percent) reported having undergone surgery without meeting one or more of the criteria, 36 (16 percent) having had less than 12 months of real life experience, 14 (6 percent) having undergone less than 12 hours
of psychotherapy, and 13 (6 percent) having undergone less than 12 months of hormone therapy before genital surgery. Of all the criteria, only the duration of real life experience was positively associated with satisfaction. This study was severely limited by a response rate of only 32 percent and did not include mental health as an outcome measure. Thus, while follow-up research has shown that the vast majority of reassigned transsexuals are satisfied (see below), no published study has examined specifically whether and to what degree psychotherapy and the real life experience predict mental health outcomes. The Standards of Care are currently being revised again, and the relevant research and recommendations for change have been published in volume 11 of the International Journal of Transgenderism (Bockting et al., 2009b).
Until recently, hormone therapy, the real life experience, and surgery were considered three steps in a linear process of sex reassignment. Various follow-up studies over the years have evaluated the outcomes of this process by assessing how well adjusted participants were as members of the other sex and their perceived satisfaction. This body of research shows that the vast majority of those who undergo sex reassignment are satisfied, and reversal to the original gender role and regrets are extremely rare (Green and Fleming, 1990; Kuiper and Cohen-Kettenis, 1988; Lawrence, 2006; Murad et al., 2010). Predictors of a good outcome include good prereassignment psychological adjustment, family support, psychological treatment, and good surgical outcomes (Carroll, 1999; Lawrence, 2003). While most of these studies have been retrospective, Mate-Kole and colleagues (1990) used a control group and found that transsexuals who had surgery relatively soon after diagnosis were socially more active and showed less neuroticism than those who were kept on a waiting list for at least 2 years.
Over the last 15 years, there has been a paradigm shift in the conceptualization of transgender identities toward recognition of greater diversity in gender identity and expression (Bockting, 2008). As a result, hormones, changes in gender role, and surgery each have become options in their own right, used either alone or in various combinations and no longer necessarily as three steps in a linear process of reassignment. Rather, clinical management of gender dysphoria now focuses largely on facilitating a transgender coming out process that may or may not include any of these medical interventions (Bockting and Coleman, 2007). Thus, individuals may explore and find a comfortable gender role and expression accompanied by hormones but no surgery, surgery but no hormones, neither, or both. Individuals may or may not change gender roles from male to female or female to male completely and permanently, may adopt both roles part time, or may grow up with a gender-variant or transgender identity without ever conforming to one role only to have to consider transitioning to another. In other words, greater acceptance and visibility of gender variance have contributed to an
environment in which there is greater room to explore and define one’s gender within or outside of a binary conceptualization of gender as either man or woman, masculine or feminine, including the adoption of such identity labels as gender variant or gender queer (Bockting, 2008).
No research to date, however, has systematically and empirically studied the natural history of transgender identity development; the clinical management of gender dysphoria under the new paradigm of a greater diversity of gender identities, roles, and expressions; or the outcomes of the interventions of hormone therapy, a change in gender role, and the various surgical options in their own right. Thus while data from a substantial number of follow-up studies show that the vast majority of transgender individuals who complete all three of the latter options are satisfied with the outcome, no studies have examined the current widespread practice of offering each as an option in its own right outside of a linear process of sex reassignment. Research on what predicts satisfaction and psychosocial adjustment in this new landscape of various interventions leading to various outcomes in terms of identity, role, and expression is entirely absent and sorely needed to inform both providers and consumers of transgender-specific health care.
PHYSICAL HEALTH STATUS
While LGBT adults have all of the same health concerns as the general population, there are some areas of physical health that are known to be distinct for sexual and gender minorities.
Very little research has been conducted on the sexual health of LGBT people, and most of it has focused on sexual dysfunction among gay and bisexual men. Evidence indicates a high rate of sexual dysfunction among all HIV-infected men (homosexual and heterosexual) (Ende et al., 2006; Lallemand et al., 2002). Very limited evidence suggests that gay men experience erectile dysfunction more than heterosexual men. In a study using a convenience sample of self-identified gay men (n = 1,196) and a matched sample of heterosexual men (n = 1,558), none of whom were HIV-positive, Bancroft and colleagues (2005) found that the gay men reported erectile dysfunction more frequently than the heterosexual men. While the authors posit that “erectile dysfunction” may mean different things to gay and heterosexual men, they also suggest that the discrepancy may be associated with anxiety or other factors.
Men who have sex with men and take medication for erectile dysfunction (either through a physician or through other sources) may demonstrate
higher rates of sexual risk taking. In a study of 342 self-identified gay men attending a pride event in Denver, Nettles and colleagues (2009) found that more than 25 percent (n = 89) reported having ever used medication for erectile dysfunction. Among this group, there were significantly more acts of sexual risk taking. Likewise, a study involving a convenience sample of 1,186 HIV-positive gay and bisexual men in New York and San Francisco demonstrated that using medication for erectile dysfunction (n = 144) was associated with unprotected insertive anal intercourse (Purcell et al., 2005). It is important to note that these studies did not determine whether respondents who used erectile dysfunction medication actually suffered from underlying problems with sexual function. The association between the use of erectile dysfunction medication and risky behaviors may be attributable to recreational use of the drugs.
A study that used primarily the Internet to recruit participants (139 married heterosexual women and 114 lesbian/bisexual women in relationships) applied a proposed ecological model to examine sexual satisfaction among women (Henderson et al., 2009). The survey results indicated that sexual satisfaction was influenced in both groups by similar factors, including relationship satisfaction and sexual functioning, suggesting that gender may play a greater role than sexual orientation in sexual satisfaction.
Transgender people may struggle with sexual functioning problems. For example, among 181 transgender-identified participants in a sexual health seminar in Minnesota aged 20–73 (141 transgender women and 34 transgender men), 38 percent reported difficulty becoming sexually aroused, 34 percent reported low sexual desire, 28 percent had difficulty reaching orgasm with a partner, and 35 percent had difficulty reaching orgasm alone (Bockting et al., 2005b). In a sample of 50 transsexual women in Belgium who had had sex reassignment surgery at least 6 months prior to the study, concerns about sexual function were reported, related in particular to arousal, lubrication, and pain (Weyers et al., 2009). While feminizing hormones would be expected to lower sexual desire, this expectation has not been unequivocally supported by empirical research (see Klein and Gorzalka, 2009, for a review). Research on the effects of masculinizing hormone therapy on sexual functioning among transgender men is limited; however, findings to date show increased sexual arousal and orgasmic ability (Klein and Gorzalka, 2009). Orgasmic ability after male-to-female genital reconstructive surgery appears to have improved with advances in surgical technique over the years; 85 percent of a sample of 232 patients of a U.S. surgeon reported achieving orgasm, with 67 percent reporting it as pleasurable or more pleasurable than before surgery (Lawrence, 2005).
Apart from studies of sexually transmitted infections (STIs) that are relevant to reproductive capabilities, very little research has focused specifically on reproductive health among LGBT adults. Reproductive health
(as distinct from sexual health) can be defined as the ability to have or not have children at a time and with a partner of one’s choosing. A few studies based on small, nonrepresentative samples suggest that pregnancy loss may be particularly difficult for lesbian women (Peel, 2010; Wojnar, 2007) and that lesbian and bisexual women may be at higher risk than heterosexual women for postpartum depression (Ross et al., 2007; see also Trettin et al., 2006). Among transgender individuals, hormone therapy may have an effect on fertility, although little research has been conducted on the reproductive health needs of this population.
Little research exists on patterns of motherhood or access to assisted reproductive technology among sexual-minority women. The American Society for Reproductive Medicine explicitly states that programs should treat all requests for assisted reproduction equally without regard to marital status or sexual orientation, and the American College of Obstetricians and Gynecologists states that sexual orientation should not be a barrier to fertility services for achieving pregnancy (American College of Obstetricians and Gynecologists, 2005; Ethics Committee of the American Society for Reproductive Medicine, 2009). In a study examining 2,431 self-identified lesbians and bisexual women and the coming out process, Morris and colleagues (2002) found that younger mothers were more likely than older mothers (those over 50) to have used nontraditional methods to conceive (e.g., donor insemination). They also found that, compared with mothers who had children before coming out, mothers who had children after coming out were more likely to have done so through insemination by a donor, through adoption, or through foster placement.
Unfortunately, many areas of reproductive health among LGBT adults remain entirely unstudied. These include the effects of hormone therapy on the fertility of transgender individuals and its implications for family planning in terms of both contraception and reproductive options (De Sutter, 2001, 2009). A survey of an international convenience sample of 121 transgender women demonstrated the desire for gamete banking prior to the onset of hormone therapy to allow for future insemination (De Sutter et al., 2002).
The most comprehensive repository for cancer statistics in the United States is the National Cancer Institute’s Surveillance Epidemiology and End Results database. Information is collected on incidence, prevalence, and survival for specific geographic areas, and mortality data are collected for the entire country. Demographic data, including age, race/ethnicity, sex, education, income, and geographic location also are collected. However, no data are collected on sexual orientation and gender identity, making it
impossible for researchers to use this database to estimate the incidence and prevalence of cancer among sexual and gender minorities.
In 1999, when the Institute of Medicine report Lesbian Health was published, insufficient research had been conducted to determine whether lesbians were at greater risk for breast cancer than heterosexual women. Unfortunately, 12 years later the same is true. While the relative risk of breast cancer for lesbians and heterosexual women is the topic of much discussion, a definitive answer is still unavailable. It is believed that lesbians may be at higher risk for breast cancer because there is some evidence that they have a higher prevalence of certain risk factors, including nulliparity, alcohol consumption, smoking, and obesity. The evidence comes from a number of studies. Using cohort data from the Nurses’ Health Study II (NHSII), Case and colleagues (2004) compared women from the cohort who identified as lesbian (n = 694) or bisexual (n = 317) with the cohort’s heterosexual women (n = 89,812). They found that the lesbian and bisexual women were more likely to be nulliparous, were more likely to be overweight and obese (lesbians more so than bisexual women), had higher smoking rates, and were more likely to report having 60 or more alcohol-containing drinks a month. Diamant and colleagues (2000c) used data from the Los Angeles County Health Survey on 4,610 women who self-identified as heterosexual, 51 who self-identified as lesbian, and 36 who self-identified as bisexual. They found that the lesbians and bisexual women were significantly more likely to report tobacco use and were more likely to report drinking alcohol frequently and in greater quantities compared with the heterosexual women. Another study, using data from the California Health Interview Survey, a population-based telephone survey, found a significantly higher prevalence of cigarette smoking among self-identified lesbians (n = 343) and bisexual women (n = 511) than among heterosexual women (n = 24,830) (Tang et al., 2004). A more recent population-based study used aggregated data from the 2001–200 Massachusetts Behavioral Risk Factor Surveillance System surveys. The authors found that lesbians (n = 719) were more likely to be obese but not more likely to be overweight than heterosexual women (n = 39,701), while there were no significant weight differences between bisexual (n = 432) and heterosexual women (Conron et al., 2010). Although binge drinking was not defined in this study, it was found that lesbians and bisexual women were more likely to binge drink and be current smokers than their heterosexual peers. As some of these risk factors are associated with other cancers, most notably lung cancer (smoking), it is likely that women who have sex with women may be at greater risk for some cancers than heterosexual women.
It has long been established that men who have sex with men have a greater risk for anal cancer (Koblin et al., 1996). Anal cancer is associated
with infection by the human papillomavirus (HPV), which is often sexually transmitted (Ryan et al., 2000), and individuals practicing receptive anal intercourse are at a higher risk for this infection (Daling et al., 2004). People with AIDS are at an increased risk for HPV-associated cancers, including anal cancer (Chaturvedi et al., 2009), although it is not known whether this greater risk is associated with AIDS-related immunosuppression or other cofactors for such cancers. In a study involving four cities, 1,218 HIV-negative men who have sex with men were tested for anal HPV, which was detected in 57 percent of the sample (Chin-Hong et al., 2004). In this study, a history of receptive anal intercourse and five or more male sex partners in the preceding 6 months appeared to be predictive of HPV infection. Other studies have shown prevalence rates of HPV infection in HIV-negative gay and bisexual men ranging from 61 to 78 percent (Friedman et al., 1998; Palefsky et al., 1998). Among HIV-positive homosexual and bisexual men, the prevalence of anal HPV infection may be as high as 93 percent (Palefsky et al., 1998). Unlike the prevalence of cervical HPV infection, which peaks during the third decade of life in women, the prevalence of anal HPV infection is steady throughout the life course of men who have sex with men, well into the sixth decade of life (Chin-Hong et al., 2004).
Similar to screening for cervical cancer, screening for anal cancer may be performed with cytology to detect HPV-associated disease (Palefsky, 2009). Currently, there exist no guidelines recommending routine anal cancer screening and no consensus on the optimal method or frequency of such screening (Palefsky, 2009). Some studies have recommended screening HIV-negative homosexual and bisexual men every 2 or 3 years (Goldie et al., 2000) and screening HIV-positive homosexual and bisexual men annually (Goldie et al., 1999). To date, however, there have been no randomized clinical trials evaluating many aspects of anal cancer screening, and the natural history of progression from precursor lesion to cancer is unknown (Wong et al., 2010).
Research on cancer among the transgender population has been extremely limited. For example, there have been no long-term prospective studies of breast cancer among transgender women. However, case reports have been published of breast cancer among transgender women who have taken feminizing hormones (Ganly and Taylory, 1995; Pritchard et al., 1988; Symmers, 1968) and transgender men who have taken masculinizing hormones and undergone chest surgery, as some breast tissue remains after such surgery (Burcombe et al., 2003; Eyler and Whittle, 2001). Transgender men on testosterone therapy may be at increased risk for ovarian cancer (Hage et al., 2000; Pache et al., 1991), and cases of prostate cancer have been reported among transgender women taking feminizing hormones (Markland, 1975; van Haarst et al., 1998).
Much of the research on cardiovascular disease in LGBT populations has focused on the increased risk of such disease among those infected with HIV and among transgender individuals taking masculinizing hormones. However, not enough research has been conducted to firmly establish these risks. One prospective observational study involving male (n = 17,816) and female (n = 5,652) participants from previously established cohorts in Europe, Australia, and the United States suggests that antiretroviral treatment may be associated with cardiovascular events, such as myocardial infarction (Friis-Moller et al., 2003). Gooren and colleagues (2008) analyzed the effects of hormone therapy on a number of known risk factors for cardiovascular disease among male-to-female and female-to-male transgender patients at a clinic in the Netherlands. They found that patients receiving hormone treatment experienced both positive and negative changes in relation to certain risk factors but were unable to conclude whether the treatment had a significant effect on the risk of cardiovascular disease. More recently, Elamin and colleagues (2010) conducted a meta-analysis to examine the cardiovascular effects of hormone treatment on transsexuals. While they did not find significant effects of hormones on cardiovascular events, the authors note that the quality of the evidence was very low, and in many cases the data were insufficient to permit drawing conclusions. Their meta-analysis does suggest that hormone therapy may increase serum triglycerides in transsexuals.
One study of 4,135 women aged 18–64 in Los Angeles County examined cardiovascular health among self-identified lesbian, bisexual, and heterosexual women. Results showed that lesbians were significantly more likely than heterosexuals to receive a diagnosis of heart disease. For bisexual women, the risk for heart disease, although less than that of lesbians, was also elevated relative to heterosexual women, even though bisexual women were the youngest group in the sample (Diamant and Wold, 2003).
Some research suggests that lesbians and bisexual women have a higher risk of obesity than heterosexual females. As discussed previously, Case and colleagues (2004) found that lesbians and bisexual women were more likely to be overweight or obese than heterosexual women (and lesbians were more likely to be overweight or obese than bisexual women). In the study conducted by Cochran and colleagues (2001), also discussed previously, a greater prevalence of obesity was found among lesbians/bisexual women than in national estimates for women generally. For purposes of the study, the authors grouped lesbians and bisexual women together. Boehmer and
colleagues (2007) used population-based data from the National Survey of Family Growth to compare lesbians’ rates of obesity and being overweight with those of bisexual and heterosexual women. They found that lesbians were more likely to be obese or overweight than bisexual women, heterosexual women, and women who identified as “something else.” These data, in conjunction with findings of earlier studies, suggest that lesbians may be at greater risk for obesity and the health problems it may cause.
A number of studies have examined why lesbians, and in some cases bisexual women, are more obese and overweight than heterosexual women. Suggested theories include an association with the impact of minority stress, more positive body images, different exercise patterns, and childhood sexual abuse; however, insufficient research has been conducted to understand these associations.
HIV/AIDS and Other Sexually Transmitted Infections
Despite substantial changes over three decades, the HIV epidemic still exacts a severe toll on men who have sex with men in the United States (CDC, 2009a). However, rates of HIV diagnosis among all age groups are higher in black men who have sex with men than in other racial or ethnic groups of men who have sex with men in the United States (Hall et al., 2007). Given the magnitude and distribution of unrecognized HIV infection among young men who have sex with men, especially black men who have sex with men, the HIV epidemic continues at a rapid pace in this population, at least in part because many young HIV-infected men who have sex with men are unaware of their infection and unknowingly expose their partners to HIV (MacKellar et al., 2005). Studies also have found HIV prevalence to be substantially greater among male-to-female than among female-to-male transgender persons (Clements-Nolle et al., 2001) and the prevalence of HIV/STIs to be low among white and very high among Latino and black male-to-female transgender persons (Nuttbrock et al., 2009b).
Numerous risk factors for HIV transmission among gay and bisexual men have been identified, including lack of knowledge of HIV serostatus (Marks et al., 2009), nonsupportive peer norms (Hart et al., 2004), optimistic beliefs about HIV treatment (Ostrow et al., 2002; Sullivan et al., 2007), greater numbers of male sexual partners, unprotected intercourse with HIV-positive partners, and amphetamine or heavy alcohol or drug use before sex (Koblin et al., 2006). While use of the Internet to obtain partners has been increasing among men who have sex with men, the evidence appears to be inconclusive as to whether Internet use encourages or discourages risky sexual behavior (Carballo-Dieguez et al., 2006; Garofalo et al., 2007).
Notably, there is conflicting evidence on risk behavior in men who have sex with both men and women, regardless of whether they identify as
bisexual. In one study examining data from the 2002 Urban Latino Men’s Health Survey, such men appear to be more likely to practice unprotected intercourse with their male partners (Munoz-Laboy and Dodge, 2007). Another study examining behavioral bisexuality and condom use based on data from the 2002 cycle of the National Survey of Family Growth found that bisexually active men, when reporting on their most recent same-sex encounter, cited the same condom use as heterosexual or homosexual men. Of interest, when condom use was based on most recent female partner, bisexually active men appeared to exhibit higher rates of condom use than either homosexually active or heterosexually active men (Jeffries and Dodge, 2007). Another study comparing men who have sex with men only (n = 97) with men who have sex with both men and women (n = 175) and men who have sex with women only (n = 775) found that the men who have sex with both men and women were less likely than the men who have sex with men only to be HIV-positive or to engage in unprotected receptive anal intercourse, but more likely than the men who have sex with women only to be HIV-positive and to engage in anal intercourse with female partners. However, compared with the men who have sex with men only, the men who have sex with both men and women were not significantly more likely to report unprotected anal intercourse with female partners (Zule et al., 2009). Spikes and colleagues (2009) found that HIV-positive black men with both male and female sexual partners engaged in more sexual and drug risk behaviors than their heterosexual and gay peers.
In a systematic review of 29 studies presenting data on HIV and transgender populations, Herbst and colleagues (2008) identified a number of risk factors for transgender women. Specifically, they found that transgender women in these studies had multiple sex partners who were predominantly male, had casual sex, and had sex while they were intoxicated or high. The percentage of transgender women who engaged in sex work ranged from 24 to 75 percent across 17 studies, with the weighted mean being 41.5 percent. No data on transgender men’s risk factors were included in the meta-analysis because the findings from the handful of studies that addressed these factors were too limited. It is important to note the limitations on the generalizability of these findings. The studies included in this review used small samples, ranging from 19 to 515 participants; nearly half included fewer than 100 transgender individuals. Studies also were restricted in their geographic diversity, with some places, such as San Francisco, being oversampled and most studies being limited to urban areas. Further, since most of the studies used convenience sampling methods, participants engaging in HIV risk behaviors may have been overrepresented.
Another meta-analytic study (Crepaz et al., 2009) suggests that most HIV-positive men who have sex with men protect their partners during sexual activity, but a sizable percentage continue to engage in sexual behaviors
that place others at risk for HIV infection and place themselves at risk for other STIs. Still other evidence (Parsons et al., 2005) suggests that some HIV-positive men who have sex with men appear to engage more in harm reduction strategies—for example, serosorting (selecting sexual partners based on HIV serostatus) and strategic positioning (assuming the receptive or insertive position during sexual intercourse according to HIV serostatus, with the receptive position posing the greater risk of transmission)—than in withdrawal before ejaculation during anal intercourse.
While studies with racial and ethnic minority men are urgently needed, strong evidence from a meta-analysis suggests that individual-, group-, and community-level behavioral interventions are effective in reducing the risk of acquiring sexually transmitted HIV in adult men who have sex with men (Herbst et al., 2007). As this analysis shows, and the social ecology model predicts, there are multiple levels at which interventions can have an impact on individual behavior.
Far less research on HIV has been conducted with women who have sex with women. According to Lesbian Health (IOM, 1999), prevalence rates of HIV among women who have sex with both women and men were higher than those among exclusively heterosexual or exclusively homosexual women. More recently, it has been noted that while female-to-female transmission of HIV appears to be possible, there have been no confirmed cases (CDC, 2008).
Although HIV has overwhelmed the field of STIs, there are other STIs of concern. In 2009, 42 clinics at 12 sites across the United States submitted STI and HIV data to the Centers for Disease Control and Prevention (CDC). Results from these clinical sites showed a median prevalence of 14.9 percent for gonorrhea overall among men who have sex with men (with a range of 6.5 to 27.9 percent). The median prevalence of chlamydia among men who have sex with men was 11.2 percent (with a range of 4.5 to 18.5 percent). Primary and secondary syphilis increased between 2005 and 2009, with men who have sex with men accounting for 62 percent of all primary and secondary syphilis cases in the United States (CDC, 2010). Median clinic syphilis seroreactivity (used as a proxy for syphilis prevalence) among men who have sex with men tested for syphilis increased from 4 percent in 1999 (range of 3 to 13 percent) to 11 percent in 2008 (range of 8 to 17 percent) (CDC, 2009b). STI (including HIV) positivity varied by race and ethnicity but tended to be highest among black men who have sex with men. Median positivity for STIs was higher among HIV-positive than among HIV-negative men who have sex with men (CDC, 2009b). In a recent study of 212 HIV-infected men who have sex with men, the baseline prevalence of asymptomatic STIs was found to be 14 percent (Rieg et al., 2008). Studies also suggest that gonorrhea and syphilis rates have been
increasing among men who have sex with men in recent years (Fox et al., 2001; Heffelfinger et al., 2007).
While less research has been conducted on STIs among women who have sex with women, Diamant and colleagues (2000a) note that self-identified lesbians participate in a variety of sexual activities that may put them at risk for acquiring STIs. Drawing on a convenience sample of 1,200 self-identified lesbian and bisexual women, Stevens and Hall (2001) found that 20 percent of the women who were sexually active with men reported having unprotected anal, oral, and vaginal sex. Of the women who were sexually active only with women, 56 percent reported having unprotected oral, vaginal, and anal sex, as well as sharing uncovered dildos and sex toys. Lack of knowledge about risk behavior and disease transmission was also notable in this population.
Transgender-Specific Physical Health Status
As mentioned in the discussion of mental health status, some research has been conducted on the impact of hormone therapy and surgery on gender dysphoria. However, limited research has examined the effects and side effects of hormone therapy on physical health (e.g., Gooren et al., 2008; Moore et al., 2003), and no clinical trials on the subject have been conducted. This research, conducted mainly abroad, indicated a risk of venous thromboembolic disease and elevated levels of prolactin associated with feminizing hormone therapy, and elevations in liver enzymes, loss of bone mineral density, and increased risk for ovarian cancer associated with masculinizing hormone therapy (Dizon et al., 2006; Hage et al., 2000; Van Kesteren et al., 1997, 1998). Research on increased risk for cardiovascular disease remains inconclusive, in part because of methodological limitations of studies conducted to date (Elamin et al., 2010; Gooren and Giltay, 2008). Little research, beyond case studies, has examined the cosmetic and functional outcomes of genital reconstructive surgery (Klein and Gorzalka, 2009; Lawrence, 2006).
RISK AND PROTECTIVE FACTORS
The literature addresses a number of risk factors that affect the health of LGBT adults. Conversely, research on protective factors is largely lacking.
The primary risk factors for LGBT adults examined in the literature are stigma, discrimination, and victimization; violence; substance use; and childhood abuse.
Stigma, Discrimination, and Victimization
Lesbians, gay men, and bisexual people are often the targets of stigma and discrimination because of their sexual orientation. In a 2005 national survey with a probability sample of self-identified lesbian, gay, and bisexual adults (n = 662), approximately 16 percent of lesbians and 18 percent of gay men reported they had experienced discrimination in employment or housing because of their sexual orientation (Herek, 2009a). Other studies with nonprobability samples also have shown that lesbian, gay, and bisexual adults are at risk for victimization because of their sexual orientation (Herek et al., 1999; Huebner et al., 2004; Otis and Skinner, 1996). Some evidence suggests that lesbians, gay men, and bisexual people have both lifetime and day-to-day experiences with bias and discrimination more frequently than heterosexual people. An analysis of data from the MIDUS survey, mentioned earlier in the chapter, found that self-identified homosexual and bisexual adults reported both lifetime and day-to-day experiences with discrimination more frequently than heterosexuals, and 42 percent attributed the discrimination partially or entirely to their sexual orientation (Mays and Cochran, 2001).
Not surprisingly, experiences with discrimination and victimization have negative effects on psychological well-being. In the MIDUS study, perceived discrimination was positively associated with indicators of psychiatric morbidity as well as harmful effects on quality of life (Mays and Cochran, 2001). Swim and colleagues (2009) found that everyday experiences with relatively minor incidents of prejudice based on sexual orientation were associated with elevations in negative mood (Swim et al., 2009). Szymanski (2005) examined the effects of external and internalized heterosexism and sexism on mental health in a study of 143 women who self-identified as lesbian (92 percent), bisexual (6 percent), and unsure (2 percent) and found that all three variables were related to psychological distress in the lesbians. Similarly, based on an Internet survey (n = 210), gay and bisexual men’s experiences of sexual stigma—including harassment, rejection, and discrimination—appear to be associated with psychological distress (Szymanski, 2009).
While little research has examined the additive effects of various forms of social discrimination—including antigay violence, discrimination, and harassment—one study found higher levels of psychological distress in gay and bisexual Latino men. Such experiences were also associated with social isolation and low self-esteem (Diaz et al., 2001).
Because of the unique discrimination faced by bisexual men and women from both heterosexual and homosexual people, some studies using small samples have examined bisexual people’s perception of their own identity. Results of a study comparing bisexual and lesbian/gay adults (n = 613)
showed that the bisexual adults reported higher levels of identity confusion (uncertainty about one’s sexual orientation) and lower levels of self-disclosure and community connectedness than the lesbian and gay adults (Balsam and Mohr, 2007). Another, smaller study (n = 43) using qualitative methods to explore minority stress among bisexual men and women, gay men, and lesbians showed that the bisexual men and women felt that both heterosexual and homosexual individuals can have biased opinions of bisexual people. Bisexual participants felt that some members of the gay and lesbian community perceived bisexuality as an inauthentic identity and viewed bisexuals as promiscuous (Hequembourg and Brallier, 2009). Bisexual participants reported feeling invisible and indicated that they lacked comfortable social spaces catering to bisexual people. Bisexual participants also reported concealing their bisexual identity to blend in better in gay/ lesbian or heterosexual social spaces (Hequembourg and Brallier, 2009).
Research with convenience samples of transgender people in various communities across the United States highlights a high prevalence of enacted stigma and discrimination based on gender identity. In a study of 402 transgender people, 56 percent reported verbal harassment, 37 percent employment discrimination, and 19 percent physical violence (see below) (Lombardi et al., 2001). Among a sample of 248 transgender people of color in Washington, DC, 43 percent reported having been a victim of violence or crime and 13 percent of sexual abuse; 43 percent attributed this victimization to homophobia and 35 percent to transphobia (Xavier et al., 2005).
The extent to which transgender individuals are accepted within the LGB community has not been adequately studied. Qualitative data from a convenience sample of transsexual men with a gay or bisexual identity revealed mixed acceptance (Bockting et al., 2009a). Among a convenience sample of lesbian and feminist women, attitudes toward transsexuals were generally positive, particularly for those who knew a transgender person personally (Kendal et al., 1997).
Sexual minorities are at particular risk for hate or bias crimes based on their minority status; they may also be at risk for intimate partner violence. While the vast majority of studies focus on male victims, females in gay populations also frequently experience antigay violence. Convenience samples have revealed a high level of violence against transgender people as well (Lombardi, 2001; Xavier et al., 2005). As a result of hate crimes based on sexual orientation, lesbian and gay survivors have been found to manifest significantly more symptoms of depression, anger, anxiety, and posttraumatic stress compared with lesbian and gay victims of comparable
crimes unrelated to their sexual orientation (Herek et al., 1999; see also Huebner et al., 2004; Otis and Skinner, 1996).
Data from the Federal Bureau of Investigation (2010), as well as some studies based on probability samples, suggest that hate crimes based on sexual orientation are prevalent in the United States. Using a probability sample of 912 Latino self-identified gay and bisexual men living in New York City, Miami, and Los Angeles, Diaz and colleagues (2001) found that 10 percent of this sample reported experiencing violence as an adult due to their sexual orientation. Similarly, a report by the Kaiser Family Foundation (2001), based on a probability sample of 405 lesbian, gay, and bisexual adults, found that 32 percent of the sample had ever been targeted for violence because of their sexual orientation. In a study using data from the Knowledge Networks panel (n = 662), Herek (2009b) provides prevalence estimates of hate crimes among self-identified lesbian, gay, and bisexual adults. Approximately 20 percent of respondents reported they had experienced a crime against their person or property based on their sexual orientation, with gay men being more likely than lesbians or bisexuals to have had such experiences. More than one-third of gay men (38 percent) reported experiencing hate crimes against their person or property, compared with 11–13 percent of lesbians, bisexual men, and bisexual women (Herek, 2009b).
Beyond hate crimes, couples with same-sex partners may also be at risk for intimate partner violence. Few studies have examined intimate partner violence in probability samples of same-sex partners. Tjaden and colleagues (1999), using data from the National Violence Against Women Survey, examined intimate partner violence in same- and different-sex cohabitating relationships (n = 8,000 men, 8,000 women), although sexual orientation was not assessed. Among the 1 percent of respondents (65 men, 79 women) in a current or past same-sex cohabitating relationship, rates of physical and sexual assault by a same-sex partner were similar for men and women. However, men experienced violence from a male partner at a rate similar to that of women with a male partner but more often than men or women with a female partner (Tjaden et al., 1999). Greenwood and colleagues (2002) examined battering victimization in intimate relationships in a probability sample (n = 2,881) of men who have sex with men from San Francisco, Los Angeles, Chicago, and New York. More than a third of the men reported at least one form of abuse.
Much research has focused on substance use among LGB adults, most of it suggesting that substance use is a problem for these populations. However, the most definitive evidence is available from population-based studies of substance use in heterosexual and nonheterosexual samples.
Studies have shown that nonheterosexuals have higher rates of smoking than heterosexuals, although typically in comparisons among women. Burgard and colleagues (2005) examined tobacco use among heterosexually and homosexually experienced women in the California Women’s Health Survey (1998–2000), a large, annual statewide health surveillance survey of women in the state. Sexual orientation was based on self-reports of same-gender behavior. The authors found that the homosexually experienced women were more likely than the exclusively heterosexually experienced women to currently smoke.
Case and colleagues (2004) examined differences in health risk factors and physical functioning between heterosexual and self-identified lesbian/ bisexual registered nurses in a prospective cohort (n = 116,671) recruited from 14 U.S. states for the NHSII. Compared with the heterosexual nurses, the lesbian and bisexual nurses had a higher prevalence of current and past smoking. Similarly, Conron and colleagues (2010) provide evidence of differences in smoking and drug use between heterosexuals and gays/lesbians from the Massachusetts Behavioral Risk Factor Surveillance System surveys (n = 67,359), an annual stratified household sample of adults in Massachusetts. Sexual orientation was based on self-reported sexual identity, which included gay or lesbian (2 percent), bisexual (1 percent), and heterosexual (97 percent). For purposes of analysis, respondents identifying as gay or lesbian were combined. Compared with the heterosexual adults, the sexual-minority respondents were more likely to report current and past smoking and any 30-day drug use.
Gruskin and colleagues (2007) compared prevalence rates of tobacco use among LGB individuals and the general population in California. Data on LGB individuals (n = 1,950) were collected using a large-scale population-based survey of tobacco use, while data on the general population (n = 20,525) were taken from the California Tobacco Survey; sexual orientation was determined by sexual self-identity and sexual behavior. Results showed that lesbians, bisexual women, and women who have sex with women were more likely to be daily, nondaily, or former smokers than women in the general California population. In the case of men, the prevalence of tobacco use was higher among gay men than among men in the general population; no significant differences in smoking were observed between bisexual men and men in the general population. Disparities in tobacco use between the LGB populations and the general population were still evident after controlling for key demographic variables.
Drabble and Trocki (2005) examined patterns of use of smoked substances (cigarettes and marijuana) using data from the 2000 National Alcohol Survey, a population-based telephone survey of adults aged 18 and older in the United States. Sexual orientation was defined as lesbian or gay self-identified (n = 36), bisexual self-identified (n = 50), hetero-
sexual self-identified with same-sex partners in the past 5 years (n = 71), and exclusively heterosexual self-identified reporting no same-sex partners (n = 3,723). The authors found that, relative to the exclusively heterosexual women, the odds of past-year tobacco use were more than three times greater in the bisexual women and two times greater in the heterosexual women reporting same-sex partners. There was no significant difference in past-year tobacco use between the lesbians and exclusively heterosexual women. Using the same data set, Trocki and colleagues (2009) examined tobacco and marijuana use among lesbians (n = 36), gay men (n = 57), heterosexual men (n = 3,201) and women (n = 3,723) with only different-sex partners, bisexual men (n = 27) and women (n = 50), and heterosexual self-identified men (n = 83) and women (n = 71) with same-sex partners. They found that the bisexual and heterosexual women reporting same-sex partners had higher rates of cigarette smoking than the exclusively heterosexual women. They also found significantly higher rates of marijuana use among the bisexual women, lesbians, and heterosexual women with same-sex partners than among the exclusively heterosexual women. Among the gay men, marijuana use was significantly greater and tobacco use was elevated compared with the heterosexual men. These findings suggest that marijuana and tobacco use differ by sexual identity, particularly among women.
With regard to alcohol use, several population-based studies suggest that nonheterosexual women consume alcohol in greater amounts and more frequently and may be at greater risk of alcohol dependency than heterosexual women. Cochran and Mays (2000b) examined differences in psychiatric syndromes among homosexually and heterosexually active women and men in the 1996 National Household Survey of Drug Abuse. Homosexually active women were more likely than other women to be classified as having alcohol or drug dependency syndromes. Other evidence (Gilman et al., 2001), based on the previously mentioned National Comorbidity Survey, provides support for similar differences in alcohol use between women with same-sex and different-sex partners. Women with same-sex partners had a significantly earlier onset of alcohol use disorders than women with different-sex partners.
Burgard and colleagues (2005) examined alcohol use among heterosexually and homosexually experienced women using data from the California Women’s Health Survey, described above. Sexual orientation was based on self-reports of same-gender behavior. Findings revealed that the homosexually experienced women were more likely than the exclusively heterosexually experienced women to consume alcohol more frequently and in greater quantities. Also, recently bisexually active women were more likely than women who were exclusively heterosexually active to report consuming alcohol in the past month, had more drinks per drinking day, and exhibited drinking patterns indicative of being binge drinkers.
Similar findings are available from comparisons of alcohol consumption among women who identified their sexual orientation as heterosexual, lesbian, or bisexual in a prospective cohort from the NHSII (Case et al., 2004). The authors found that lesbians and bisexual women were significantly more likely than heterosexual women to report having engaged in heavy drinking, defined as consuming 60 or more alcohol-containing drinks a month.
Drabble and colleagues (2005) examined the prevalence of drinking and alcohol-related problems among homosexual, bisexual, and heterosexual respondents in the 2000 National Alcohol Survey (n = 7,248). Sexual orientation was based on both self-identity and behavior, which yielded four categories of participants: homosexual, bisexual, heterosexual with same-sex partners, and exclusively heterosexual. Few significant differences were found among men by sexual orientation, with the only significant finding being that the gay men had lower abstention rates than the exclusively heterosexual men. By contrast, both the heterosexual women with same-sex partners and the bisexual women had significantly lower abstention rates than the exclusively heterosexual women. The lesbians and bisexual women also had significantly greater odds of reporting alcohol-related social consequences and alcohol dependence (according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth revision [DSM-IV]) than the exclusively heterosexual women.
In the previously mentioned study by Drabble and Trocki (2005), other differences in alcohol use were found among the four groups of female participants. Compared with the exclusively heterosexual women, the mean number of drinks per year was elevated among the lesbians, bisexual women, and women who self-identified as heterosexual but reported same-sex partners. When demographic variables were controlled, however, the only significant difference was between the exclusively heterosexual women and the heterosexual self-identified women with same-sex partners. When looking at alcohol consumption in different contexts, the authors found that the heterosexual self-identified women who reported same-sex partners were more likely both to frequent bars and to drink heavily in bars relative to the exclusively heterosexual women. The bisexual self-identified women were less likely to frequent bars, but were more likely to drink heavily in both bars and party contexts compared with the exclusively heterosexual women (Drabble and Trocki, 2005).
In a study using survey data from 1996–1998, Scheer and colleagues (2002) examined sexual and drug use behaviors among women who have sex with women who resided in low-income neighborhoods in Northern California. Based on sexual behavior, the respondents, aged 18–29, included women who had sex exclusively with men (n = 2,229), women who had sex with both men and women (n = 189), and women who had sex
exclusively with women (n = 16). Compared with the women who had sex exclusively with men, the women who had sex with both men and women were more likely to report past and recent injection drug use.
Stall and colleagues (2001) examined alcohol and recreational drug use among urban men who have sex with men (n = 2,172) using data from the Urban Men’s Health Study. The study sample included self-identified gay and bisexual men as well as men who reported a sexual encounter with another man in the past 5 years. Fifty-two percent of the sample reported recreational drug use and 85 percent reported alcohol use in the past 6 months. Further, 8 percent of the men who have sex with men engaged in frequent/heavy drinking (five or more drinks at a sitting at least once a week), 18 percent used three or more recreational drugs, and 19 percent used recreational drugs at least once a week.
Harawa and colleagues (2008) examined the role of drug use and addiction in sexual behavior by conducting focus groups with 46 nongay self-identified black men of predominantly low socioeconomic status. The authors identified drug use as playing a central role in same-sex sexuality, with participants describing alcohol and drug use and addiction and sex–drug transactions as being closely linked to same-sex sexual behavior (Harawa et al., 2008).
Many studies have found an association between nonheterosexual orientation and increased risk of substance use. However, McCabe and colleagues (2009) found significant variation in substance use outcomes across gender and sexual orientation definitions. Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 34,653 participants aged 20 and older), the authors found that most sexual-minority respondents did not report substance use or meet criteria for substance dependence. However, they also found that the effects of sexual-minority status on substance use and dependence were greater for sexual-minority women than for sexual-minority men, although this finding may be a result of the overall higher rates of substance use and dependence among men in the general population (McCabe et al., 2009).
While a meta-analysis of prior mental health research found that lesbian, gay, and bisexual individuals had a 1.5 times higher risk of alcohol and other substance dependence over 12 months compared with heterosexual individuals (King et al., 2008), data from convenience samples suggest that substance use may be a major concern among transgender people as well. Eighteen percent of 392 transgender women and 4 percent of 123 transgender men in San Francisco and 23 percent of 332 transgender women of color in San Francisco reported injection drug use. Fully 48 percent of 248 transgender people of color in Washington, DC, reported a problem with alcohol and drugs (Xavier et al., 2005). A previously mentioned study of 207 transgender individuals, 480 men who have sex with
men, and 122 behaviorally bisexual women participating in a sexual health seminar assessed substance use among these three groups. Among transgender participants, 20 percent reported abusing alcohol, compared with 30 percent of men who have sex with men and 16 percent of bisexual women; 16 percent of transgender participants used marijuana, compared with 26 percent of men who have sex with men and 24 percent of bisexual women; and 3 percent of transgender participants used other drugs, compared with 9 percent of men who have sex with men and 2 percent of bisexual women (Bockting et al., 2005a).
A small amount of research has documented higher rates of childhood abuse among sexual-minority men and women. Using data from the NHSII, Austin and colleagues (2008) compared rates of childhood abuse among self-identified lesbian, bisexual, and heterosexual women. They found that, compared with heterosexual women, lesbians and bisexual women were more likely to report physical and sexual abuse during childhood and adolescence. In a newer study using the same data set, Austin and Irwin (2010) showed that increased physical and sexual abuse among self-identified lesbian and bisexual women was positively associated with risk of tobacco and alcohol use as well as greater use in adolescence. Another study examining data from the National Survey of Midlife Development in the United States compared childhood maltreatment experiences among 2,917 self-identified heterosexual (n = 2,844), homosexual (n = 41), and bisexual (n = 32) individuals aged 25–74. For the purposes of analysis, homosexual and bisexual respondents were grouped together. The authors found that, compared with the heterosexual respondents, the homosexual/ bisexual respondents reported higher rates of major physical maltreatment by their parents.
While little is known about experiences of childhood sexual abuse among sexual minorities, some evidence, derived from a probability sample of urban men who have sex with men (n = 1,078), suggests that such abuse may be common (20 percent) among sexual-minority men (Catania et al., 2008). Moreover, a few studies suggest that childhood sexual abuse may be linked with negative health outcomes in adulthood. In a study examining risk factors for obesity among a community sample of lesbians (n = 416), childhood sexual abuse was associated with obesity even after adjusting for age, race/ethnicity, and education (Aaron and Hughes, 2007). Similarly, high rates of childhood sexual abuse among a probability sample of Latino gay and bisexual men (n = 912) predicted HIV and mental health outcomes (Arreola et al., 2009). Feldman and Meyer (2007a) examined the relationship between childhood sexual abuse and eating disorders
in a community sample of 193 self-identified white, black, and Latino gay and bisexual men and found that 33 percent of the sample had experienced childhood physical abuse, and 34 percent had experienced childhood sexual abuse. They also found that childhood sexual abuse was a predictor of subclinical or full-syndrome eating disorders. Little is known about racial and ethnic variation in the prevalence of childhood sexual abuse, but a recent study of 669 LGB men and women found that black and Latino participants reported the highest rates of childhood sexual abuse, while Latinos and Asian Americans reported the highest rates of childhood physical abuse (Balsam et al., 2010). In a nonprobability sample of 181 transgender seminar participants in Minnesota, 23 percent of participants reported childhood sexual abuse and 38 percent childhood physical abuse (Bockting et al., 2005b).
Although research on protective factors is sparse, small studies suggest the possibility of a few factors that may be protective, all of which require more research. For example, one protective factor may be living and/or working in supportive environments. Hatzenbuehler and colleagues (2010) examined the psychological impact on sexual minorities of living in states with constitutional amendments banning marriage among same-sex couples and found a statistically significant increase in the rates of generalized anxiety disorder and mood and alcohol use disorders among LGB participants over a 3-year period. Sexual minorities who lived in states that did not have such amendments showed no significant increases in psychiatric morbidities. Similarly, a national study of lesbians, gay men, and bisexual people explored the antecedents affecting the degree to which they disclosed their LGB identities in the workplace. The authors found that employees had less fear of disclosing and disclosed more often when they worked in a group that seemed supportive and shared their stigma (Ragins et al., 2007). An earlier study that focused on workplace discrimination found that organizational policies and practices were strongly associated with perceived discrimination (Ragins and Cornwell, 2001).
Support from family and friends may be another protective factor. A study found that perceived social support for romantic relationships predicted greater relationship well-being and, in turn, more positive mental and physical health outcomes; this was true for both same-sex and mixed-sex partners (Blair and Holmberg, 2008). In surveying 340 self-identified gay men aged 18–78, illoughby and colleagues (2008) found that social networks of adult gay men may play important roles in both the promotion and prevention of health risk. Similarly, in a study of 106 self-identified Latino lesbians and gay men aged 20–53, social support, active coping, and
identification with the Latino gay and lesbian community were all associated with psychological well-being (Zea et al., 1999).
Studies have shown that positive health effects are associated with marriage (Herdt and Kertzner, 2006; Herek, 2006). These positive effects derive in part from the economic impact of the benefits, rights, and privileges available to married couples, as well as the increased social support and relative stability associated with a legally recognized commitment (Herek, 2006). Preliminary research has indicated that same-sex couples in legally recognized relationships experience greater psychological benefits than those in similar long-term relationships that lack legal recognition (Riggle et al., 2010).
Using survey data collected in 1994, Luhtanen (2003) measured self-esteem, life satisfaction, and depression among groups of lesbians/bisexual women (n = 168) and gay/bisexual men (n = 152) aged 19–73. For purposes of the study, lesbians and bisexual women were combined and analyzed as a group, as were gay and bisexual men. The most robust predictor of psychological well-being in both groups was having a positive LGB identity (Luhtanen, 2003). In a study of 182 lesbian and bisexual women, Singh and colleagues (2006) found that participants with higher levels of social ease (defined as the level of comfort with others in social situations) or higher levels of self-disclosure (defined as communication of a personal nature with others) had less internalized homophobia. Of interest, the authors did not find a significant relationship between levels of internalized homophobia and social support or financial freedom (Singh et al., 2006).
Many of the protective factors of health among sexual minorities may be considered to contribute to their resiliency. Definitions of resilience vary, ranging from a risk factor that has been averted or unrealized (Keyes, 2004), to a phenomenon that involves a relatively good outcome despite one’s suffering risk experiences (Rutter, 2007), to a class of phenomena characterized by patterns of positive adaptation in the context of significant adversity or risk (Masten and Reed, 2002). Despite these differing definitions, studies typically focus on the capacity to recover from psychological trauma or to adapt successfully to adversity. Indeed, resilience per se is not directly observable and can only be inferred by observing a person’s adaptation (Masten, 2007). Minority stress theory (Meyer, 2003), discussed briefly in Chapter 1, posits that individuals from stigmatized social groups experience excess stress and negative life events due to their minority status in addition to the general stressors experienced by all people, and consequently must have greater capacity for adaptation. Moreover, various social structures, institutions, and processes beyond the individual contribute further to the experience of minority stress. Meyer (2003) contends that minority stress includes both internalized and external stress processes that can cause negative mental health outcomes. Resilience represents one
category of variables, in addition to social support and coping, that can affect the association between minority stress and distress. Most research on resiliency factors involves studies with heterosexual children, adolescents, and adults. The studies cited in this section include the few notable exceptions that have examined resiliency factors associated with health among gay and lesbian adults. More research on the impact of resilience on the association between risk factors and health outcomes in sexual-minority populations is warranted.
The limited amount of research on transgender people has focused less on protective factors than on the factors associated with positive outcomes of sex reassignment. These factors, mentioned earlier in this chapter, include psychological adjustment, family support, psychological treatment, and good surgical outcomes (Carroll, 1999; Lawrence, 2003).
Most of the available research on the interactions of LGBT adults with various aspects of the health system tends to focus on the different patterns of access to and utilization of health care services by the LGBT community. Very few studies have examined how lack of access and utilization affects the health status of LGBT populations, an area that requires more research. Similarly, the literature tends to focus on processes of care rather than on the outcomes of the delivery or quality of care.
Access and Utilization
The limited research available suggests that LGBT adults have different patterns of access and utilization of health care services than heterosexual adults. For example, Sanchez and colleagues (2007) compared 360 self-identified LGB individuals and 10,000 adults in New York City and found that the former had higher rates of emergency department use than the general population. In another example, Kerker and colleagues (2006) conducted a multilingual population-based survey in New York City to determine the use of Pap tests and mammograms among women who have sex with women (n = 269). They found that these women were significantly less likely than other women to have had a Pap test in the past 36 months or a mammogram in the past 24 months. Earlier research had yielded similar findings (Cochran et al., 2001; Diamant et al., 2000b; Marrazzo et al., 2001).
Much of the research that specifically examines access issues for sexual minorities relates to the use of mental health services. One study, examining data from the MIDUS survey, found that individuals who self-identified as either homosexual or bisexual used mental health services more than
did self-identified heterosexual individuals (Cochran et al., 2003). In a comparison of a convenience sample of self-identified lesbians (n = 63) and a matched sample of self-identified heterosexual women (n = 57), Razzano and colleagues (2002) found that lesbians in their sample used mental health services, as well as alcohol and drug-related services, significantly more than heterosexual women. Specifically among black women, Matthews and Hughes (2001) compared a convenience sample of lesbians, defined by behavior and attraction measures (n = 70), with a sample of heterosexual women (n = 40) and found that the lesbians attended counseling or therapy at significantly higher rates than their heterosexual counterparts. In a previously mentioned study, Page (2004) found that bisexual men and women were less likely to seek help for sexual orientation issues and rated services as less helpful relative to lesbian and gay respondents in comparable research.
Some research suggests that use of preventive screening may be less frequent among lesbians and bisexual women than among heterosexual women. In a study using pooled data from seven separate surveys conducted between 1987 and 1996, Cochran and colleagues (2001) compared data on approximately 12,000 women who have sex with women against national estimates for women. Of the surveyed women in the pooled data, most self-identified as lesbian, with a much smaller percentage self-identifying as bisexual and an even smaller percentage self-identifying as other/ heterosexual. The authors found that self-identified lesbians/bisexual women were less likely to have had a pelvic examination in the last 5 years than women in the general population and that lesbians/bisexual women in their 40s were less likely to have received a mammogram. It should be noted that when pooling the data, the authors combined the samples of lesbians and bisexual women. Another study examining use of preventive services among lesbians (n = 524), bisexual women (n = 143), and heterosexual women (n = 637) found that the bisexual women were the least likely to undergo mammography (Koh, 2000).
In a study conducted by Diamant and colleagues (2000c), described above, self-identified lesbians, but not bisexual women, were significantly less likely than heterosexual women to have had a Pap test or a clinical breast exam within the previous 2 years. However, the authors found that for women aged 50 and older, there was no difference in receiving mammograms between heterosexual women and lesbians, nor were there differences between bisexual and heterosexual women in receiving Pap tests, clinical breast exams, or mammograms. More recently, Buchmueller and Carpenter (2010) used data from the 2000–2007 Behavioral Risk Factor Surveillance System to compare women in same-sex and different-sex relationships. They found that women in same-sex relationships were significantly less likely than women in different-sex relationships to have had
recommended mammograms or Pap tests in the last 3 years. Even when insurance coverage was equalized across the groups, the gap in preventive care services remained.
The literature also points to a number of barriers that may influence LGBT individuals’ interactions with health services. Such barriers include lack of health insurance, fear of discrimination from providers, lack of knowledge on the part of providers, lack of perceived severity of medical conditions, and dissatisfaction with services (Heck et al., 2006; Nemoto et al., 2005; Newman et al., 2008; Owens et al., 2007; Rhodes and Diclemente, 2003; van Dam et al., 2001).
Perceived discrimination by health care providers may be a significant barrier to access to and utilization of health care services. A few studies have examined different providers and their attitudes toward sexual-minority patients. Javaherian and colleagues (2008) collected qualitative and quantitative data from a questionnaire administered to occupational therapy practitioners (n = 1,051) to assess comfort levels in working with lesbian, gay, or bisexual patients. They found that while most of the providers felt comfortable and prepared to work with sexual-minority patients, less than 20 percent of the sample had received education in this area. A study based on a convenience sample of providers of substance abuse treatment (n = 46) showed wide variability in their attitudes toward sexual-minority patients (Cochran et al., 2007a). While this range of attitudes is likely to exist in the general population, provider attitudes could affect the success of treatment in the context of a substance abuse treatment program. In a qualitative assessment of training needs among providers of HIV-related care to transgender people (n = 13), providers admitted discomfort with interviewing such patients, stated a need for more standards and guidelines for their care, and acknowledged a lack of understanding of distinct transgender identities and the nuances of transgender-specific care (Lurie, 2005). Using qualitative interviews, Simpson and Helfrich (2007) asked providers to identify barriers that prevented lesbians from accessing services for intimate partner violence. The providers identified systemic barriers that reflect cultural attitudes, institutional barriers that originate in the policies of service agencies, and individual barriers that emerge from individual attitudes. Training and education interventions to impact the attitudes of providers, such as that described by Kelley and colleagues (2008) for medical students, hold promise for addressing these issues.
An earlier study (Smith et al., 1985) of 424 bisexuals and 1,921 lesbians found that 40 percent of each group believed that disclosing information to physicians about their sexual preference would hinder the quality of their medical care. About one-third of each group had not disclosed their sexual behavior, although they wanted to, because physicians had not asked. Another study examined LGB people’s (n = 88) disclosure of
sexual identity to health care providers and found that many respondents reported previous negative interactions with providers and avoided discussing sexuality with providers (Eliason and Schope, 2001). While many of these studies had sampling limitations, they highlight potential barriers that deserve further scrutiny.
Research with convenience samples of transgender people indicates that lack of access to health care is an important concern for this segment of the LGBT community. Access to transgender-specific health care in accordance with the Standards of Care varies across the United States (Rachlin et al., 2008). One major barrier is that, with some notable exceptions, health insurance and other third-party payers (Medicare, Medical Assistance) exclude coverage of transgender-specific health care, particularly surgery. The cost of medical care, lack of access to specialists, and a paucity of transgender-friendly and -knowledgeable providers are perceived barriers to care. On the other hand, being under the care of a physician is associated with reduced high-risk behavior, such as smoking cessation, medically supervised hormone therapy, and access to clean needles for hormone injection (Sanchez et al., 2009).
The recently conducted National Transgender Discrimination Survey (n = 6,456), described in detail in Chapter 3, reported that 28 percent of transgender respondents experienced verbal harassment in a medical setting, and 50 percent encountered providers that lacked knowledge of some aspect of their health needs (Grant et al., 2010). Qualitative research supports the finding that transgender people often have negative experiences when interacting with health care providers who lack the cultural competence to respond sensitively to their health concerns (Bockting et al., 1998; Clements-Nolle et al., 1999; Sperber et al., 2005). In a survey using a convenience sample of 248 transgender people of color in Washington, DC, 33 percent reported insensitivity or hostility from health care providers; 11 percent reported difficulty accessing transgender-specific health care procedures (counseling, hormone therapy, or surgery to alleviate gender dysphoria), and 70 percent of those taking hormones had acquired them from friends or on the street (Xavier et al., 2005). Participants in this survey indicated multiple needs for general and transgender-specific health care services not currently met. Among 332 transgender women of color in San Francisco, needs for general health care services were high and generally met; however, this was often not the case for social services, substance use treatment, psychological counseling, and transition-related medical services. Further focus group findings (n = 48) indicated that this population was generally dissatisfied with the quality of available health and social services (Nemoto et al., 2005). Similarly, a survey of transgender people in Philadelphia (n = 81) found high levels of need for health and social services that were largely unmet, especially among female-to-males (Kenagy, 2005a).
Quality of Care
Very little research has been conducted on the quality of care experienced by sexual and gender minorities. A limited amount of research has explored the preferences of lesbian, gay, and bisexual patients with respect to receiving care. Findings indicate that satisfaction among sexual-minority patients is associated with a number of factors, including the provider’s LGB-specific knowledge, the competency of care, and sensitivity to areas of concern for sexual minorities (Burckell and Goldfried, 2006; Saulnier, 2002; Seaver et al., 2008). Page (2007) explored self-identified bisexual men and women’s (n = 217) experiences with psychotherapy and found that respondents viewed knowledge of bisexual-specific issues and validation of bisexual identity as important to a positive patient–provider relationship. As mentioned above, some research suggests that the quality of care received by transgender people is affected by a lack of culturally competent providers (Bockting et al., 1998; Clements-Nolle et al., 1999; Sperber et al., 2005). In a convenience sample of 122 female-to-male transgender persons ranging in age from 18 to 60, Rachlin and colleagues (2008) found mixed reviews of health care services. About one-third of respondents rated the care they received as either poor or fair; about one-quarter rated their health care provider’s sensitivity to their needs as “a trans person” as either “horrible” or poor or fair.
Some literature examines specific care environments for LGBT populations. For example, Brown and McDuffie (2009) surveyed prison systems in the United States regarding the care provided to transgender inmates. They found wide variability in terms of access to sex hormones, with some systems allowing continuation of treatment, some requiring that hormone treatment be stopped, and others allowing the initiation of treatment. In a survey of substance abuse services specializing in LGBT clients, Cochran and colleagues (2007b) found no difference between the specialized services offered to LGBT clients and those offered to the general population. These studies are limited by their lack of generalizability, however.
At the University of Minnesota, results from five consecutive patient satisfaction surveys over a 10-year period showed that satisfaction with transgender-specific health care services was high (Bockting et al., 2004). Few significant differences were found between transgender patients (n = 180) and other sexual health patients (n = 837), except that in one year, transgender patients reported higher satisfaction on their perceived ability to handle the problems that originally had led them to seek services. This is one of the very few studies examining patient satisfaction with the delivery of transgender-specific health care, and it indicates that, despite the challenges associated with the gate-keeping role (i.e., the requirement for evaluation and recommendation from a mental health
professional to access hormone therapy and surgery), high satisfaction can be achieved.
Several salient contextual influences, including sociodemographic and familial factors, influence the health of sexual- and gender-minority adults.
One prominent contextual influence on LGBT individuals is race/ ethnicity and its intersection with low socioeconomic status. While few studies have examined racial/ethnic differences in health outcomes across sexual- and gender-minority populations, some studies suggest that racial/ ethnic variability in mental disorders may exist. Using a sample of 388 New York City residents who identified as lesbian, gay, or bisexual, Meyer and colleagues (2008) found that black LGB individuals experienced a lower prevalence of all psychiatric disorders than Latino and white LGB individuals (Meyer et al., 2008). The same study also found that Latino sexual minorities attempted suicide more often than white sexual minorities. Using survey data to examine health indicators among racial and ethnic minorities, Mays and colleagues (2002) compared a sample of self-identified black and Latino lesbians obtained from a non-population-based survey (n = 365) with a sample of self-identified heterosexual black and Latino women drawn from a population-based survey. She found that black and Latino lesbians and bisexual women had some negative health outcomes compared with heterosexual women, including higher rates of obesity and increased rates of tobacco and alcohol use; they also had lower rates of health insurance coverage.
While few studies have looked at racial/ethnic differences in health outcomes in LGBT populations, even fewer have explored the effect of geography. Some small qualitative studies suggest that social isolation exists among rural LGB populations (McCarthy, 2000; Williams et al., 2005). To evaluate the health status of lesbians living in southern states, Austin and Irwin (2010) compared findings from a convenience sample of self-identified lesbians living in the south (n = 1,141) with results from CDC’s Behavioral Risk Factor Surveillance System. They found that the lesbians residing in southern states were more likely to have experienced recent depression and more likely to have engaged in risky health behaviors than women in the general U.S. population (in both southern and nonsouthern states).
Socioeconomic status is another relevant contextual factor that may affect sexual minorities. One study, examining a sample of men who have
sex with men (n = 2,605) derived from the Urban Men’s Health Study, found that as income and level of education decreased, the men who have sex with men were less likely to identify as gay, more likely to have sex with women, and less likely to be involved in the gay community (Barrett and Pollack, 2005). As mentioned in Chapter 2, evidence also suggests that there are income differences based on sexual orientation.
Cultural context based on one’s country of origin can influence the health of LGBT populations as well. Cultural norms of the home country and the ways in which they are modified by migration/immigration have been shown to affect the sexual health of Asian/Pacific Islander men who have sex with men (Chng and Geliga-Vargas, 2000). Other research suggests less tolerance toward LGB individuals in some Latin American countries than in the United States (Bianchi et al., 2007; Nierman et al., 2007). It should be noted, however, that laws in both Argentina and Mexico City allow marriage between same-sex couples. Research on the sexuality of Asian and Latino people in the United States has been sparse, and many of the studies that have been conducted suffer from sampling problems and other methodological limitations. However, some data are available from probability samples and are discussed elsewhere in this report (e.g., Chae and Ayala, 2010; Cochran et al., 2007c; Diaz et al., 2001).
Some research, discussed below, examines gay men and lesbians in terms of families, and a very small amount of research looks at transgender family life. However, the committee could find no research on the family lives of bisexual people. Studies of partnering relationships typically refer to same-sex or different-sex couples. The experiences of bisexual people in these relationships do not appear to be reflected in research.
As noted in Chapter 2, gay men and lesbians are less likely to become parents than their heterosexual peers (Gates et al., 2007; Patterson, 2004; Patterson and Riskind, 2010). Results from the 2002 National Survey of Family Growth (NSFG) revealed that 35 percent of self-identified lesbians (aged 15–44) reported having given birth to at least one child, compared with 65 percent of same-aged heterosexual women. In the 2002 NSFG, only 16 percent of self-identified gay men reported having a biological or adoptive child, compared with 48 percent of same-aged heterosexual men (Gates et al., 2007; Patterson and Riskind, 2010). Thus, available data suggest that while fewer lesbian and gay than heterosexual adults become parents, many lesbian and gay adults do become parents.
Why are there fewer lesbian and gay than heterosexual parents? Lesbian and gay adults may be less likely to become parents in part because they have fewer unplanned pregnancies. However, data from the 2002
NSFG reveal that both gay men and lesbians endorse the value of parenthood as strongly as their heterosexual peers and that many childless gay and lesbian adults express the desire to become parents (Riskind and Patterson, 2010). Among gay men in particular, however, there appears to be a sizable gap between the desire for parenthood and actual intentions, such that many who want to have children do not actually intend to become fathers (Riskind and Patterson, 2010). The psychological burden of infertility among heterosexual individuals is acknowledged to be great, but it has not been studied among lesbian, gay, or bisexual populations.
The health implications of greater childlessness among lesbian and gay populations across the life course, although potentially sizable, have gone essentially unstudied. As discussed earlier, for example, nulliparity is an established risk factor for some cancers. For this reason, lesbians’ reduced likelihood of childbearing may place them at higher risk than their heterosexual peers for certain diseases.
When lesbian and gay individuals do become parents, they may do so through multiple pathways (Goldberg, 2009; Patterson and Riskind, 2010). Some marry different-sex partners and have biological, adoptive, or foster children before coming out. Others have children after coming out through the use of donor insemination, surrogacy, heterosexual intercourse, adoption, and/or foster parenting. Increasing numbers of same-sex partners live in jurisdictions that provide legal recognition of their relationship, but the implications of this for parenting have not yet been studied. The increasing availability of assisted reproductive technology to nonheterosexual adults has opened up new possibilities for family formation among members of sexual minorities, but research likewise has not yet fully explored these issues. In short, modes of family formation among lesbian and gay adults are diverse; however, the life-course consequences of different choices for the adults who make them have not yet received much systematic study.
The parenting abilities and competencies of lesbian and gay adults have been explored in a number of small-scale studies (Goldberg, 2009; Golombok and Badger, 2010; Patterson, 2004), a few of which have identified special strengths or difficulties. For example, one study, based on a convenience sample of 256 families, found lesbian and gay parents to be less likely than others to report using physical punishment as a discipline technique (Johnson and O’Connor, 2002); this type of difference would be expected to have positive consequences for children of lesbian and gay parents. On the other hand, a study based on a convenience sample of 87 lesbian mothers in the United States and Canada revealed that those in the United States (who lived in states that did not provide legal recognition of marriage between same-sex couples) expressed more anxiety about legal problems and discrimination based on sexual orientation than those in Canada, whose family relationships enjoyed the protection of law (Shapiro
et al., 2009). In general, research has shown lesbian mothers and gay fathers to be very similar to matched groups of heterosexual parents with respect to their parenting attitudes and practices, although studies based on representative samples generally are not available (Golombok and Badger, 2010).
Considerable research has focused on development among the children of lesbian and gay parents, and some of these studies have been based on representative or near-representative samples. In a study of 7-year-olds drawing on the Avon Longitudinal Study of Parents and Children, conducted in the United Kingdom, Golombok and colleagues (2003) found that children of lesbian mothers were well adjusted on a series of standardized assessments of socioemotional development, and similar in this regard to the offspring of heterosexual mothers. In a study based on U.S. census data, Rosenfeld (2010) found that, once demographic characteristics of families had been taken into account, children of same-sex and different-sex couples were making progress through school at about the same rates (i.e., were no more and no less likely to have been held back a grade in school), and that both groups of children were making more rapid progress through school than children living in group quarters. In studies based on data from Wave I of the National Longitudinal Study of Adolescent Health (a near-representative sample of adolescents in the United States), Wainright and colleagues (2004) found that adolescents living with same-sex parents did not differ from those living with different-sex parents on measures of psychosocial adjustment, school outcomes, peer relations, romantic relationships, delinquency, victimization, or substance use (Wainright and Patterson, 2006, 2008; Wainright et al., 2004).
Findings of studies of representative samples of the children of lesbian and gay parents have been consistent with those of studies based on smaller and/or convenience samples. The findings show similar patterns of adjustment among children and adolescents growing up with lesbian, gay, and heterosexual parents across a broad spectrum of measures, including overall adjustment, gender development, peer relationships, and social and academic competence (Biblarz and Stacey, 2010; Goldberg, 2010a; Patterson, 2009). Especially notable among recent reports are extensions of these findings to samples of adoptive children and adolescents, as well as to samples of those with gay fathers in addition to lesbian mothers (Erich et al., 2009; Farr et al., 2010). In a study based on a convenience sample of 78 17-year-old offspring of lesbian mothers, Gartrell and Bos (2010) found that the adolescents were developing in positive ways, such as showing greater social and academic competence than a normative sample of same-aged adolescents with heterosexual parents. Overall, the results of research to date suggest that the offspring of lesbian and gay parents are generally well adjusted.
There has been relatively little research on parenting among transgender adults or on development among the children of transgender parents.
What research has been reported suggests that substantial proportions of transgender adults are parents (Erich et al., 2008). Moreover, research on children of transgender parents has found them to be developing in normal ways (Green, 1978, 1998). This is a nascent area of research, however, and any conclusions must be viewed as preliminary.
The results of research to date on lesbian and gay parents and on their children, although clear, are nevertheless subject to a number of limitations (Goldberg, 2010b; Tasker and Patterson, 2007). In large part because of the absence of sexual orientation assessments in national survey data sets, large representative samples of these populations have rarely been studied. Longitudinal or observational studies are still uncommon. Moreover, research on low-income families, as well as on ethnic, racial, or religious minorities, has remained relatively scarce. There are only a handful of studies on children of transgender parents, and these are based on small convenience samples.
Among adults, family support and acceptance play an important role in psychological adjustment. For transgender adults, higher perceptions of the quality of their family’s relationship have been shown to be associated with healthier levels of life satisfaction and self-esteem (Erich et al., 2008). This study involved 91 self-identified transsexuals gathered by a snowball technique from a convenience sample. However, not all transgender individuals receive sufficient family support. In a study involving 20 transwomen of color, the majority of respondents reported hostility and aggression from their families (Koken et al., 2009).
When families do not provide adequate support, many LGBT individuals create families of choice composed of friends. Research shows mixed levels of support from families of choice and families of origin for lesbians who choose to become mothers. Using a convenience sample of self-identified lesbians, DeMino and colleagues (2007) found that, compared with lesbians without children (n = 42), lesbian mothers (n = 47) felt that they received less support from their friends, including their gay and lesbian friends, and more support from their families of origin. A study of couples becoming parents through adoption found that lesbian couples (n = 36) perceived less support from their families than heterosexual couples (n = 39). Levels of support from friends and general well-being were similar for both groups (Goldberg and Smith, 2008).
SUMMARY OF KEY FINDINGS AND RESEARCH OPPORTUNITIES
Given the length of the phase of life represented by early/middle adulthood, it is not surprising that more data are available for this cohort than
Mental Health Status
As a group, LGB adults, largely behaviorally defined, appear to experience more mood and anxiety disorders than heterosexual adults. Little research has examined the prevalence of mood and anxiety disorders among transgender people.
LGB adults appear to be more likely than heterosexual adults to experience depression both over a period of 12 months and over a lifetime. Very limited research on transgender adults and depression has been undertaken, but studies conducted with convenience samples suggest elevated rates of risk in this population.
Studies suggest that LGB people are more likely than heterosexual people to report suicidal ideation and behavior. Some evidence indicates that suicidal ideation and behavior may vary by sexual orientation and gender. Studies of transgender people suggest their rates of suicidal ideation and behavior may be comparable to or higher than those in LGB populations.
Limited research has explored the prevalence of eating disorders within the LGBT community. These studies indicate that gay and bisexual men may be at higher risk for eating disorders compared with heterosexual men. Far less research has explored rates of eating disorders among lesbians, bisexual women, and transgender people.
Results of older studies suggest that the vast majority of individuals who underwent sex reassignment surgery are satisfied with the results. More recent research on this subject has not been conducted.
Physical Health Status
Very limited research suggests that gay men have higher rates of erectile dysfunction than heterosexual men. Little research has focused on reproductive health among LGBT people.
Lesbians and bisexual women may be at higher risk for breast cancer than heterosexual women. Some research suggests that lesbians and bisexuals have higher rates of risk factors associated with breast cancer, although the data are not clear.
Men who have sex with men, particularly those who are HIV-positive, are at increased risk for anal cancer. Currently, there exist no guidelines recommending routine anal cancer screenings and no consensus on the optimal method or frequency of such screening.
Research on health outcomes for transgender people is very limited, although some studies suggest that long-term hormone use may increase the risk for cancer. Similarly, very little research, particularly in the United States, has examined the effects and side effects of hormone treatment on physical health (including reproductive health), and no clinical trials on this subject have been conducted.
Lesbians and bisexual women may be at greater risk for obesity, although the data on bisexual women are less clear. Insufficient research has been conducted to elucidate the mechanisms of risk.
HIV continues to exact a severe toll on adult men who have sex with men, with black and Latino men being disproportionately affected. Among transgender people, little HIV research has been conducted, but small studies suggest that transgender females are at high risk.
Little research on HIV has been conducted among women who have sex with women. The few studies that exist suggest higher HIV prevalence among women who have sex with both men and women compared with exclusively heterosexual or homosexual women.
Risk and Protective Factors
LGBT people are frequently the targets of stigma and discrimination because of their sexual- and gender-minority status.
LGB adults experience violent victimization because of their sexual-minority status. Convenience samples of transgender people have yielded similar results.
Like heterosexual adults, LGB adults experience intimate partner violence. Data on the frequency and extent of such violence are extremely limited.
LGB adults appear to have higher rates of substance use (including smoking and alcohol consumption) than heterosexual adults. Most of the research on this subject has been conducted among women, with much less being known about gay and bisexual men. Limited research among transgender adults indicates that substance use is a major concern for this population.
Although the research on protective factors for LGBT adults is limited, there is some indication that such factors as supportive living/working environments, support from family and friends, and a positive LGB identity may be protective. The limited amount of research on transgender people has focused less on protective factors and more on the factors associated with positive outcomes of sex reassignment (psychological adjustment, family support, psychological treatment, and good surgical outcomes).
Very little research has been done on health outcomes resulting from LGBT people’s lack of access to and utilization of health care services.
With respect to health services, LGBT adults appear to have different access and utilization patterns. Some research suggests that sexual-minority adults access mental health services more than their heterosexual counterparts.
Some studies indicate that lesbians and bisexual women use preventive services less than heterosexual women, but these studies are not conclusive.
Lack of health insurance (including the exclusion of some services, such as sex reassignment surgery, by third-party payers), fear of discrimination from providers, and dissatisfaction with services may act as barriers to accessing all health services for LGBT adults.
Very little research has been conducted on the quality of care experienced by sexual and gender minorities.
Limited data suggest high satisfaction rates with transgender-specific health care services among transgender patients when those services are accessible from knowledgeable providers.
While limited research suggests there are racial/ethnic differences in the health of LGBT adults, very little research has examined differences based on geographic or other sociodemographic factors.
Gay men and lesbians are less likely to be parents than their heterosexual peers. The health implications of this have been largely unstudied.
Development among the children of lesbian and gay parents has received a great deal of attention. Studies show that these children are well adjusted and developmentally similar to the children of different-sex parents. Limited research suggests that substantial numbers of transgender people are parents, and their children appear to be developing in healthy ways.
Although a number of studies provide useful information on the health status of LGBT adults, very limited data exist in some areas. The research that has been conducted has been uneven in that it has been much less likely to focus on bisexual and transgender people, and within-group differences
have seldom been examined. In addition, many of the available studies have relied on small convenience samples. There are many opportunities for additional research. Both cross-sectional and longitudinal research is needed on the intersection of contextual factors (e.g., race, geography, socioeconomic status), attending to multiple levels of consideration (e.g., community, structural, biomedical), with respect to sexual- and gender-minority status. Similarly, research is needed to address the risk and protective factors associated with, as well as interventions to promote, health and well-being in LGBT populations. The following topics in LGBT health research would benefit from additional study:
Demographic and descriptive information, including the percentage of adults who are LGBT and how that percentage varies by demographic characteristics such as race, ethnicity, socioeconomic status, geography, and religion; also, the percentage of LGBT adults who are parents, as well as the general experiences and health status of LGBT adults and how these vary by demographic characteristics.
Family and interpersonal relations, including the effect of the greater likelihood of childlessness in LGBT populations and their experience of parenting (with a particular focus on the experience of gay, bisexual, and transgender parents, which is largely absent from the research literature); the experience and prevalence of “chosen families”; and the experience of intrafamily and domestic violence (such as intimate partner violence), as well as anti-LGBT victimization.
Health services, including barriers to access (particularly related to identity disclosure and interactions with providers), utilization rates, and quality of care received.
Mental health, including eating disorders, the prevalence of depression and suicidality (particularly unknown among transgender adults), and the effects of stigma and discrimination (particularly unknown among bisexual adults).
Physical health, including substance use (particularly among transgender individuals); cancer rates, risks, and treatment (e.g., breast cancer among lesbians and bisexual women; anal cancer rates and evaluations of the effectiveness of screening among men who have sex with men; cancer among transgender adults in general, about which very little is known); cardiovascular disease among all LGBT adults; and obesity (particularly among lesbian and bisexual women).
Sexual and reproductive health, including HIV rates and interventions (particularly addressing racial disparities); fertility, infertility, and reproductive health issues; and reproductive technology and its use.
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