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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Understanding the Well-Being of LGBTQI+ Populations Committee on Understanding the Well-Being of Sexual and Gender Diverse Populations Charlotte J. Patterson, Martín-José Sepúlveda, and Jordyn White, Editors Committee on Population Division of Behavioral and Social Sciences and Education A Consensus Study Report of Prepublication copy – uncorrected proofs

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and Gilead Sciences (award no. 05352), the Sexual and Gender Minority Research Office of the National Institutes of Health (award no. 75N98019F00850), Robert Wood Johnson Foundation (award no. 75874), the TAWANI Foundation (unnumbered), and the Tegan and Sara Foundation (unnumbered). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25877 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. (2020). Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. https:// doi.org/10.17226/25877. Prepublication copy – uncorrected proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. Prepublication copy – uncorrected proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. Prepublication copy – uncorrected proofs

COMMITTEE ON UNDERSTANDING THE STATUS AND WELL-BEING OF SEXUAL AND GENDER DIVERSE POPULATIONS CHARLOTTE J. PATTERSON (Cochair), Department of Psychology, and Center for Children, Families and the Law, University of Virginia MARTÍN-JOSÉ SEPÚLVEDA (Cochair), Health Systems and Policy Research, IBM Corporation (retired); CLARALUZ Consulting LLC M.V. LEE BADGETT, Department of Economics, University of Massachusetts Amherst MARLON M. BAILEY, Department of Women and Gender Studies, School of Social Transformation, Arizona State University KATHARINE B. DALKE, Department of Psychiatry, Pennsylvania State University College of Medicine ANDREW R. FLORES, Department of Government, American University GARY J. GATES, Williams Institute (retired) ANGELIQUE C. HARRIS, Department of Medicine, Boston University Medical Campus, Boston University MARK L. HATZENBUEHLER, Department of Psychology, Harvard University NAN D. HUNTER, Georgetown University Law Center TONIA C. POTEAT, Department of Social Medicine, University of North Carolina Chapel Hill SARI L. REISNER, Brigham and Women’s Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, and Fenway Health STEPHEN T. RUSSELL, Department of Human Development and Family Sciences, University of Texas at Austin DEBRA J. UMBERSON, Population Research Center, University of Texas at Austin JORDYN WHITE, Study Director KELLAN BAKER, Consultant, Bloomberg School of Public Health, Johns Hopkins University KENNE DIBNER, Senior Program Officer TARA BECKER, Program Officer MARY GHITELMAN, Senior Program Assistant MALAY K. MAJMUNDAR, Director, Committee on Population Prepublication copy – uncorrected proofs v

COMMITTEE ON POPULATION KATHLEEN MULLAN HARRIS (Chair), Department of Sociology, Carolina Population Center, and National Longitudinal Study of Adolescent to Adult Health, University of North Carolina at Chapel Hill DEBORAH BALK, Marxe School of Public and International Affairs, and CUNY Institute for Demographic Research, Baruch College of the City University of New York NANCY BIRDSALL, Center for Global Development, Washington, DC ANN K. BLANC, Population Council, New York, NY COURTNEY C. COILE, Department of Economics, Wellesley College VICKI A. FREEDMAN, Institute for Social Research, University of Michigan DANA A. GLEI, Georgetown University ROBERT A. HUMMER, Department of Sociology, and Carolina Population Center, University of North Carolina at Chapel Hill HEDWIG (HEDY) LEE, Department of Sociology, Washington University in St. Louis JENNIFER J. MANLY, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Department of Neurology, Columbia University EMILIO A. PARRADO, Department of Sociology and Population Studies Center, University of Pennsylvania ANNE R. PEBLEY, Department of Community Health Sciences, Department of Sociology, California Center for Population Research, Bixby Center on Population and Reproductive Health, University of California, Los Angeles ISABEL V. SAWHILL, The Brookings Institution, Washington, DC REBECA WONG, University of Texas Medical Branch at Galveston MALAY K. MAJMUNDAR, Director Prepublication copy – uncorrected proofs vi

ACKNOWLEDGMENTS In 2011 the Institute of Medicine of the U.S. National Academies of Sciences, Engineering, and Medicine (National Academies) published The Health of Lesbian, Gay, Bisexual, and Transgender People, a landmark report about the health of this population. The report discussed the existing body of research about the health of lesbian, gay, bisexual, and transgender (LGBT) people, identified opportunities for further research, and made recommendations for actions to improve the health of LGBT people. By mid-2020 the report had been downloaded more than 15,000 times, and it had been used by researchers, educators, attorneys, health care professionals, government workers, journalists, community groups, and many others. It has influenced the work of the National Institutes of Health, the Centers for Disease Control and Prevention, and other governmental and nongovernmental organizations. Since 2011 much has changed. Some of the challenges identified in the 2011 volume have been met, but others certainly remain. Research on LGBT health has burgeoned, but there is still much to learn. In 2019, the National Academies convened a committee to assess the current state of knowledge about the status and well-being of sexual and gender diverse people to identify important gaps in knowledge and to recommend research and research infrastructure actions to help fill these gaps. The committee’s work was supported by the Robert Wood Johnson Foundation, the Gilead Foundation, the Sexual and Gender Minority Research Office at the National Institutes of Health, the TAWANI Foundation, and the Tegan and Sara Foundation. The task set for the committee was broader than the one addressed by the 2011 report. The committee was charged with reviewing data on people with differences in sexual development (sometimes called “intersex”), as well as those who could, by virtue of their identities, behaviors, or attractions, either identify or be seen as LGBT. In undertaking its work, the committee was asked to address not only the mental and physical health of this population, but also additional aspects of well-being in their lives as lived in families, communities, and in the context of cultural, legal, educational, economic and religious institutions. The committee undertook to provide both an overview of existing evidence and of future research needs in these areas. Thus, this report presents a considerable body of information across a wide array of topics and disciplines. The report was made possible by a year of discussion, information gathering, review, and deliberation among committee members, aided by a dedicated staff. We thank all of the committee members for their dedication and spirit as well as for their invaluable expertise. In addition to the invited guests, reviewers, and members of the public who contributed to this report, and on behalf of the entire committee, we want to thank the National Academies staff members who made this report possible. In particular, we extend our sincere thanks to Jordyn White, study director; Kenne Dibner, senior program officer; Tara Becker, program officer; Kellan Baker, project consultant; Mary Ghitelman, senior program assistant; and Malay K. Majmundar, director of the Committee on Population. We would also like to thank Daniel Desautels for his contribution during his time at the National Academies as a Christine Mirzayan Prepublication copy – uncorrected proofs vii

Science and Technology Policy Graduate Fellow. Without the constant support and guidance from these individuals, the report could not have been completed. This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: Walter O. Bockting, Program for the Study of LGBT Health, Columbia University Irving Medical Center; Christopher (Kitt) S. Carpenter, Vanderbilt LGBT Policy Lab, Vanderbilt University; Laura E. Durso, executive director and chief learning officer, Whitman-Walker Institute; Heath Fogg Davis, Gender, Sexuality and Women’s Studies, Political Science, Temple University; Donald Haider-Markel, Kentucky University; Jennifer S. Hirsch, Department of Medicine, University of Chicago; Trevon D. Logan, Department of Economics, Ohio State University; Christy Mallory, School of Law, University of California, Los Angeles; Wendy D. Manning, Department of Sociology, Bowling Green State University; Jae M. Sevelius, Department of Medicine, Division of Prevention Science, University of California, San Francisco; and Russell Toomey, Family Studies and Human Development, University of Arizona. Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by Marshall H. Chin, Department of Medicine, University of Chicago, and Sara Rosenbaum, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. Charlotte J. Patterson and Martín-José Sepúlveda, Cochairs Committee on Understanding the Status and Well-Being of Sexual and Gender Diverse Populations Prepublication copy – uncorrected proofs viii

Contents Summary PART I: BACKGROUND AND CONTEXT Prologue 1 Introduction 1-1 Background Charge to the Committee Key Terms and Definitions Addressing the Charge Sexual and Gender Diverse Populations Inclusion of Intersex People Understanding Well-Being Committee’s Approach to the Study Methods and Approach to the Evaluation of Evidence References 2 Health and Well-Being in Diverse Populations: Frameworks and Concepts 2-1 Social Ecology Social Constructionism Stigma Intersectionality Identity Affirmation Life Course Summary References PART II: UNDERSTANDING SEXUAL AND GENDER DIVERSE POPULATIONS 3 Demography and Public Attitudes of Sexual and Gender Diverse Populations 3-1 Prevalence The Role of Public Attitudes Geographic Variation Gender and Sexual Orientation Age Race and Ethnicity Child Rearing Summary and Conclusions References 4 Current State of Data Collection 4-1 Types of Data Collection Prepublication copy – uncorrected proofs ix

Metrics and Measurement General Methodological Considerations Sexual Orientation Gender Identity Intersex Status Relationship Status Summary and Conclusions References PART III: DOMAINS OF WELL-BEING 5 Law and Legal Systems 5-1 The New Baseline Continuing Gaps in Legal Protection The Possible Loss of Physical Liberty Anti-Discrimination Laws Areas of Law that Lack Protections against Discrimination Military Service Documentation of Identity Family Law Protection against Violence Religious Liberty Exceptions to Anti-Discrimination Laws Employment Public Accommodations Summary and Conclusions References 6 Public Policy and Structural Stigma 6-1 Public Policy, Social Movements, and Public Opinion Policy Advocacy Groups Issue Framing Public Opinion and Public Policy Changing Public Attitudes Public Policy Adoption and Diffusion Structural Stigma Measurement Approaches Review of Research Establishing Causal Inferences Advancing Research on Structural Stigma Summary and Conclusions References 7 Community and Civic Engagement 7-1 The Nature of SGD Communities The Importance of Space to SGD Communities Prepublication copy – uncorrected proofs x

Physical Space Social Space Virtual Space Space in Institutions Civic and Political Involvement Summary and Conclusions References 8 Families and Social Relationships 8-1 Social and Family Relationships in Childhood and Adolescence Family Relationships Relationships with Teachers and Other Adults Peers and Friendships Romantic Partners Parenting and Other Family Relationships Family Formation Sexual and Gender Diverse Parenting and Children Other Family Ties Close Relationships in Adulthood Intimate and Romantic Relationships Chosen Families Summary and Conclusions References 9 Education 9-1 Discriminatory Experiences at School Bullying, Victimization, and Well-Being Differential Treatment in Schools Educational Attainment Education Law and School Policies School Climate Professional Education and Training School Clubs School Resources and Inclusive Curricula Sexual and Gender Diverse Parents and Their Children Summary and Conclusions References 10 Economic Well-Being 10-1 Socioeconomic Status Individual Income from Earnings Household Income Poverty and Economic Insecurity Occupational Attainment and Segregation Workforce Issues Prepublication copy – uncorrected proofs xi

Employment Discrimination Compensation Discrimination Access to Military Service Workplace Disclosure of Sexual Orientation and Gender Identity Nondiscrimination Policies Housing Homelessness Home Ownership and Wealth Discrimination in Rental Housing Summary and Conclusions References 11 Physical and Mental Health 11-1 General Health and Well-Being Health-Related Behaviors Cardiovascular Disease Cancer Sexual and Reproductive Health HIV and Other Sexually Transmitted Infections Sexual Function Fertility and Contraception Violence and Victimization Mental and Behavioral Health Mental Health Substance Use and Behavioral Health Summary and Conclusions References 12 Coverage, Access, and Utilization of Evidence-Based Health Care 12-1 Coverage, Access, and Utilization Discrimination in Health Care and Health Insurance Coverage Health Insurance Coverage Health Services Utilization Quality of Care and Health Professions Training Gender-Affirming Care for Transgender People Components of Gender Affirmation Guidelines and Policies Related to Gender Affirmation Outcomes of Gender-Affirming Interventions Conversion Therapy Intersex Genital Surgery Genital Diversity and Early Genital Surgeries Gonadectomy Feminizing Surgeries Masculinizing Surgeries Psychosocial Outcomes after Genital Surgery Prepublication copy – uncorrected proofs xii

Alternatives to Genital Surgery Summary and Conclusions References PART IV: RESEARCH NEEDS 13 Recommendations 13-1 Population Data Measurement Challenges Critical Data Gaps Data Use Evidence-Based Programming and Interventions Conclusion Reference Appendixes A Summary of Prior Related National Academies Reports and Activities A-1 B Agenda: Public Seminar on Amplifying Visibility and Increasing Capacity for Sexual and Gender Diverse Populations B-1 C Biographical Sketches of Committee Members and Staff C-1 Prepublication copy – uncorrected proofs xiii

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The increase in prevalence and visibility of sexually gender diverse (SGD) populations illuminates the need for greater understanding of the ways in which current laws, systems, and programs affect their well-being. Individuals who identify as lesbian, gay, bisexual, asexual, transgender, non-binary, queer, or intersex, as well as those who express same-sex or -gender attractions or behaviors, will have experiences across their life course that differ from those of cisgender and heterosexual individuals. Characteristics such as age, race and ethnicity, and geographic location intersect to play a distinct role in the challenges and opportunities SGD people face.

Understanding the Well-Being of LGBTQI+ Populations reviews the available evidence and identifies future research needs related to the well-being of SDG populations across the life course. This report focuses on eight domains of well-being; the effects of various laws and the legal system on SGD populations; the effects of various public policies and structural stigma; community and civic engagement; families and social relationships; education, including school climate and level of attainment; economic experiences (e.g., employment, compensation, and housing); physical and mental health; and health care access and gender-affirming interventions.

The recommendations of Understanding the Well-Being of LGBTQI+ Populations aim to identify opportunities to advance understanding of how individuals experience sexuality and gender and how sexual orientation, gender identity, and intersex status affect SGD people over the life course.

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