8

Families and Social Relationships

Decades of study reveal that individuals who are relatively more socially connected are in better health and live longer than those who are relatively more socially isolated (Holt-Lunstad, Smith, and Layton, 2010). Close relationships and social connections, such as those found in families, are fundamentally important to health and well-being throughout life (Umberson and Karas Montez, 2010; Umberson and Thomeer, 2020). Supportive and stable relationships foster health and well-being, and relationships early in life have implications for the quality and stability of social ties in adolescence and adulthood. Throughout adulthood, people who are more socially connected have better mental and physical health and lower mortality than those who are more socially isolated (Yang et al., 2016).

Sexual and gender diverse (SGD) populations have not been a focus of this research to date, even though minority stress and discrimination experienced by SGD populations contribute to patterns of social engagement and patterns of isolation. Beginning in childhood, SGD populations face unique sources of stigma and discrimination due to SGD status that may introduce strain in relationships with others, inhibit family formation, and contribute to social isolation (Patterson, 2019; Riskind and Patterson, 2010; Russell and Fish, 2016). Close social ties can help individuals cope with sexual minority stress and offer sources of connection, resilience, and support that foster health and well-being (Umberson and Thomeer, 2020).

This chapter presents an overview of research findings relevant to social relationships and family lives across the life course. The discussion focuses on research about relationships in childhood and adolescence, on parenting

and parent-child relationships, and on social ties in adulthood. In assessing the evidence, attention is devoted to contexts of relationships (such as stigma and discrimination), diversity in social ties as a function of diverse identities (such as sex and gender, social and economic status, and race and ethnicity), and on factors related to risk and resilience.

SOCIAL AND FAMILY RELATIONSHIPS IN CHILDHOOD AND ADOLESCENCE

Research over recent years has found that SGD youth show high rates of behavioral, mental, and physical health risks (Institute of Medicine, 2011; Russell and Fish, 2016). These vulnerabilities are one of the earliest and most consistent areas of scientific evidence regarding the lives of SGD people (Russell and Fish, 2016). In recent years, scholars have begun to trace many such risks to experiences of stigma and discrimination, whether at home, in the form of family rejection (Parker et al., 2018), or at school, in the form of bullying by peers (Moyano and del Mar Sánchez-Fuentes, 2020).

Most of the scientific research in this area has relied on measures of sexual identity (mostly on gay and lesbian identities); there is much less empirical research on gender identity or expression and even less on the health and well-being of intersex children and adolescents. However, newer studies on transgender youth and youth who question their sexual or gender identities show results generally consistent with the pattern found for lesbian, gay, and bisexual (LGB) youth: experiences of stigma or discrimination undermine health and well-being (Connolly et al., 2016; Russell and Fish, 2016). To the extent that youth might experience stigma or discrimination due to differences of sex development (DSD) or intersex traits, one might expect similar patterns, but research on this population is lacking.

While SGD people in earlier generations most often came out—that is, disclosed their identities as lesbian, gay, bisexual, transgender, or queer (LGBTQ)—in young adulthood, many SGD people now come out in adolescence (Floyd and Bakeman, 2006; Martos, Nezhad, and Meyer, 2015). A study that examined sexual identity developmental milestones across groups defined by gender or race and ethnicity found that developmental milestones are generally earlier for gay men than for lesbian women, but it found no significant differences across racial and ethnic groups (Martos, Nezhad, and Meyer, 2015). An earlier study, however, suggested that disclosure of SGD identity in early adolescence may be more likely among white than among Black or Latinx youth (Rosario, Schrimshaw, and Hunter, 2004). Finally, in a recent national probability sample of sexual minority people in the United States, gay males and SGD people from more recent generations generally reported earlier milestones than those from older

generations and those with other sexual minority identities, and white participants reported later ages of some milestones than Black and Latinx participants (Bishop et al., 2020).

The shift over time in the age of coming out is especially relevant for adolescent social relationships: it means that contemporary youth come out in the context of legal, social, and financial dependence on their parents or caregivers, and during a period of life when extra-familial social relationships revolve primarily around school, a setting with few options and for which attendance is mandatory. While the potential for bullying or other forms of social rejection is greater for youth who come out (Russell et al., 2014), coming out also opens the door for positive social relationships, such as SGD-affirming friendships and romantic relationships (Russell, Watson, and Muraco, 2011; Whitton et al., 2018). Thus, over the recent past, youth have encountered experiences in families, schools, and peer groups that had not previously been encountered by SGD youth.

Family Relationships

Early studies of gay and lesbian youth described their fears of coming out at home (D’Augelli, Hershberger, and Pilkington, 1998). For many youth, coming out to parents or family members was very difficult if not impossible, and those who did come out reported experiences of family rejection ranging from guilt and shame to physical violence and being driven out of the home (Rosario et al., 2001). In an early study of LGB youth, D’Augelli and colleagues (1998) found that, when compared with youth who did not come out at home, those who did come out to family members reported more verbal and physical harassment and more suicidal thoughts and behavior. Since then, studies have assessed multiple dimensions or behaviors related to family rejection: they found strong associations between rejecting behaviors by parents and a range of emotional and behavioral health problems among LGBT youth (Puckett et al., 2015; Ryan et al., 2009). For example, LGBT youth who reported high levels of family rejection also reported more depressive symptoms, suicidal ideation, and suicidal behavior than did their peers (Ryan et al., 2009). A study of transgender adolescents (Johnson et al., 2020) and a retrospective survey of transgender adults identified similar correlates of family rejection in adolescence and adult well-being (Klein and Golub, 2016).

The dynamics of coming out and family relationships are distinctly gendered. Youth are more likely to come out to mothers than fathers or to come out to mothers before fathers (Floyd and Bakeman, 2006; Rothman et al., 2012; Savin-Williams, 2001), and reactions of fathers are usually feared more than reactions from mothers (Heatherington and Lavner, 2008). Like the gendered pattern of relations with parents, SGD youth report that their

sisters are more likely to be confidants for disclosure of SGD identities than are their brothers (Toomey and Richardson, 2009).

Negative family experiences among SGD youth are often concentrated around the time of coming out (D’Augelli, Hershberger, and Pilkington, 1998). The conflict related to a youth’s asserted SGD identity can set off relationship tension or disruption in families. In previous generations and in the context of profound stigma related to sexual and gender diversity and development, parents were often unable to understand a child’s same-sex sexuality or transgender identity (Herdt and Koff, 2000). Today, in a social context of greater awareness, positive images of SGD people in the media, and increased visibility of SGD populations, many parents are able to be more accepting of their sexual and gender variant children (Russell and Fish, 2019).

In recent years, increased public understanding of transgender identities has also made possible the growing numbers of young children who assert gender identities that are not aligned with the sex they were assigned at birth (Johnson et al., 2020; Olson, Key, and Eaton, 2015). For intersex youth, coming out to immediate families may be less relevant, since their differences of sex development are often known by parents from birth or early childhood, and they are understood as physiological sexual differences rather than differences based in personal identity and expression (Gough et al., 2008). However, routine disclosure of intersex status by physicians to patients and families is a relatively recent practice. At the same time, many intersex youth and their families still struggle over whether and how to disclose to other people (Hollenbach, Eckstrand, and Dreger, 2014). Thus, coming out experiences among SGD youth are diverse and may vary as a function of gender, race and ethnicity, and other characteristics, as well as sexual and gender identities (Grov et al., 2006; Martos, Nezhad, and Meyer, 2015; Rosario, Schrimshaw, and Hunter, 2004).

Supportive family relationships are a foundation for child and adolescent well-being. For LGB and transgender children and adolescents, accepting behaviors by parents are associated with both multiple indicators of positive youth adjustment (e.g., higher self-esteem, reported social support, and general health) and lower levels of mental and behavioral health risk (e.g., fewer depressive symptoms, less suicidality, and less substance use) (Durwood, McLaughlin, and Olson, 2017; Johnson et al., 2020; Olson et al., 2016; Ryan et al., 2010). Recent studies provide evidence of the primary role of parental support (relative to support from friends or teachers) for the mental health of youth (Shilo and Savaya, 2011; Snapp et al., 2015; Watson, Grossman, and Russell, 2019). Research on parents of intersex children has focused largely on parents’ understanding of differences of sex development and decision making regarding medical approaches to treatment (Ernst et al., 2018; Gough et al., 2008).

Relationships with Teachers and Other Adults

Teachers are among the most important nonfamily adults in the lives of youth. Having a supportive teacher has been identified as a protective factor for sexual and gender diverse students (Russell, Seif, and Truong, 2001). (This topic is treated in detail in Chapter 10.) Studies have also documented the role of other important nonfamily adults in the lives of SGD youth. For example, in a qualitative study of how they coped with school victimization, LGBT students reported the need for adult mentors as well as supportive teachers (Grossman et al., 2009).

Peers and Friendships

Studies of SGD youth and their peers have been dominated by studies of victimization or bullying (Horn and Romeo, 2010). Research documents the persistence of negative peer interactions, such as patterns of bullying, for both previous and recent cohorts of SGD students (Earnshaw et al., 2016; NASEM, 2019; Toomey and Russell, 2016). Beyond bullying, early studies documented the pain of losing of close friends when a young person comes out (D’Augelli, 2003; Diamond and Lucas, 2004) and that some SGD youth lack friends and feel lonely (Grossman and Kerner, 1998).

More recent studies have examined the potential positive social influence of peers and the positive role of friendships for SGD youth (Snapp et al., 2015; Watson, Grossman, and Russell, 2019). As they do for other youth, friendships support positive adjustment for SGD youth (Rosario, Scrimshaw, and Hunter, 2009; Shilo and Savaya, 2011). Maintaining friendships following coming out is protective: lesbian and bisexual adolescent girls reported better psychosocial adjustment when they did not lose friends after coming out (D’Augelli, 2003). Support from friends is a common and important form of social support for SGD youth (Watson, Grossman, and Russell, 2019). Importantly, studies have documented the distinctive salience of SGD friendships for SGD youth: in comparison with social support from family and heterosexual friends, LGB youth reported more social support from LGB friends, and LGB friend support was associated with fewer psychological symptoms (Doty et al., 2010).

Romantic Partners

Romantic relationships emerge in the adolescent years; most youth experience their first romantic attractions and relationships as adolescents and begin to develop relationship skills that they will carry forward into adulthood. The development of romantic relationships is normative and expected for heterosexual youth, but in some cultural or historical con-

texts, same-sex romantic relationship experiences may not have been or be possible (D’Augelli, Hershberger, and Pilkington, 1998; Savin-Williams, 1994). In some environments, youth may have been (or may still be) unable to carry on romantic relationships with partners of the same sex. In order to conform to expectations among family and peers or because they deny same-sex attractions, some avoid same-sex romantic relationships (Diamond, in press; Diamond, Savin-Williams, and Dubé, 1999). A study based on a national sample of youth who were adolescents in the mid-1990s showed that youth with same-sex romantic attractions were not less likely to date, but the majority dated different-sex partners (Russell and Consolacion, 2003). Much has changed since then, although little is known about national patterns today. Intersex youth with diverse external genitalia may experience fear of rejection by romantic partners due to anatomical differences or concerns about future fertility (Slowikowska-Hilczer et al., 2017), but there is less research in this area.

There has been significant attention to experiences of peer victimization and bullying among LGBT youth, but less attention to victimization in the context of romantic relationships. Research shows that LGBT youth are at higher risk for dating violence compared with heterosexual youth (Reuter, Sharp, and Temple, 2015). Furthermore, rates of dating violence are higher for female than male youth and for transgender than for cisgender youth (Dank et al., 2014), as well as for Black youth compared with white youth (Reuter et al., 2017). LGBT youth who report intimate partner violence reported more sexual risk-taking and compromised mental health (Reuter et al., 2017). Finally, there may be not only higher rates of victimization but also more dating violence perpetration among LGBT youth (Dank et al., 2014): one recent study documented associations between minority stressors (e.g., internalized homonegativity, concealment) and partner violence among LGBTQ college students (Edwards and Sylaska, 2013).

The advent of the internet has made a significant difference in the social lives of SGD youth. With its growth and influence, otherwise isolated SGD youth were able to find SGD peers for the first time online (Russell, 2002). The internet has allowed SGD youth to meet others like them and to build friendships and romantic relationships (DeHaan et al., 2013). LGBTQ youth may be more likely than non-LGBTQ youth to meet romantic partners online (Korchmaros, Ybarra, and Mitchell, 2015), yet LGBTQ youth remain less likely overall than their heterosexual peers to be involved in romantic relationships. Despite barriers, there is evidence from a small number of recent studies that SGD youth who develop same-sex romantic relationships in adolescence report better adjustment than those who do not develop such relationships (Bauermeister et al., 2010; Glover, Galliher, and Lamere, 2009; Whitton et al., 2018). These findings are consistent with research on the normative and positive role that romantic relationships play

in adolescent development (Russell, Watson, and Muraco, 2011). The role of positive social relationships with family members, as well as with those outside the family, is important in helping youth develop in positive ways. Intersex youth and adults tend to report fewer sexual partners, with some evidence that intersex individuals report later initiation of sexual activity (Kreukels et al., 2019).

PARENTING AND OTHER FAMILY RELATIONSHIPS

This section presents information based on research on family formation, parenting, children, and other family ties, ending with a discussion of the concept of “chosen family.”

Family Formation

Parenthood is one of the most universal and highly valued of human experiences (Bornstein, 2019). LGBTQ people are, however, less likely than heterosexual individuals to want or intend to have children or to become parents (Goldberg, 2010; Patterson, 2019; Reczek, 2020). Studies of nationally representative datasets have shown that adult lesbian women and gay men are less likely than their heterosexual peers to express desire for parenthood. Indeed, sexual minority women may be more likely than heterosexual women to have pregnancies that were not planned (Everett, McCabe, and Hughes, 2017). In addition, gay men who desire parenthood are less likely than their heterosexual peers to expect that they will attain it (Riskind and Patterson, 2010). Researchers have explored reasons for these disparities, and they have identified relevant contextual as well as individual-level variables (Tate and Patterson, 2019a). In contrast, desires for parenthood among bisexual men and women seem to be more similar to those among heterosexual individuals (Riskind and Tornello, 2017; Simon et al., 2018). The study of parenting desires and intentions among intersex and transgender people is only beginning (Tornello and Bos, 2017). Some intersex traits are associated with infertility, but some are not, and fertility has gained increased attention in clinical care and research (Slowikowska-Hilczer et al., 2017). Many intersex people desire and achieve parenthood through assisted or unassisted conception, adoption, and surrogacy, though little research has explored these pathways to parenthood.

There is some recent evidence that lower desire and expectation for parenthood in SGD populations may be related to lower expectations (but not desires) over a broad range of life goals (Tate and Patterson, 2019c). In a convenience sample of 368 lesbian, gay, and heterosexual young adults, participants were asked about their desires and expectations with respect

to life goals in a number of areas, such as marriage, parenthood, friendship, and career. With the exception of desire for parenthood, which was lower among sexual minority respondents, lesbian and gay young adults reported desires that were very similar to those of heterosexual peers, but they described expectations that were consistently lower for most other aims. Thus, lesbian and gay young adults reported life aims that were similar to those of heterosexual peers, but they did not believe that they would achieve them (Tate and Patterson, 2019c). These results suggest that lower parenting desires among SGD adults may be part of a larger pattern and may reflect social and cultural constraints.

Despite divergent overall rates of desires and expectations, many SGD people become parents, and they do so through many pathways. However, the numbers of SGD parents in the United States are difficult to estimate. Using 2014–2016 data from the American Community Survey (ACS), Goldberg and Conron (2018) estimated that there are currently just over 700,000 households headed by same-sex couples, of which approximately half are headed by male couples and half by female couples (Goldberg and Conron, 2018). In this sample, 39 percent of male-female couples, 8 percent of male couples, and 24 percent of female couples described themselves as parents of children 18 years of age or younger (Goldberg and Conron, 2018). Census and ACS data do not include information on sexual or gender identity, so those identifying as lesbian, gay, bisexual, transgender, or queer cannot be identified from these data. Similarly, census and ACS data cannot identify nonresidential parents or households headed by single SGD parents. As a consequence, estimates of parenthood among SGD population based on census and ACS data are likely to provide an undercount of these families.

Some SGD people become parents in the context of heterosexual relationships (Patterson, 2013). For example, a gay man or lesbian woman could have married a partner of a different sex and had children; the couple could have subsequently divorced when one of them came out as non-heterosexual. Some findings suggest that this pathway to parenthood is more common among older people and less common among younger individuals (Tornello and Patterson, 2015), but it remains an important pathway to parenthood among LGBT people in the United States (Goldberg and Conron, 2018).

Another pathway to parenthood among LGBTQ+ people involves the use of assisted reproductive technology, such as sperm donation, egg donation, in vitro fertilization, surrogacy, and related procedures (Blake et al., 2017; Golombok, 2015, 2019). People who cannot produce sperm may pursue sperm donation and artificial insemination; people who cannot produce eggs or do not have uteruses may pursue egg donation and gestational surrogacy (Golombok, 2015). The costs of such techniques can be

high, so access to these options is limited to those with substantial financial resources.

Legal or policy issues vary across states and may also provide obstacles for some LGBTQ+ people who wish to become parents (Farr, Vazquez, and Patterson, 2020). For example, in addition to its high economic costs, surrogacy is legally banned in some jurisdictions and highly regulated in others (Green et al., 2019). Thus, access to reproductive technology among SGD individuals and couples may be greater for those with substantial economic resources and for those who live in states or local jurisdictions that legally permit the technology (see Chapter 5).

Adoption and foster care are also pathways to parenthood that are pursued by many LGBTQ+ people (Farr, Vazquez, and Patterson, 2020). Recent estimates based on data from the 2014–2016 ACS suggest that same-sex couples are far more likely than male-female couples to be foster or adoptive parents: 21 percent of same-sex couples were adoptive parents, compared with only 3 percent of male-female couples, and 3 percent of same-sex couples were foster parents, compared with only 0.4 percent of male-female couples (Goldberg and Conron, 2018). In addition to the issues that may be encountered by heterosexual people who hope to foster or adopt children, additional obstacles may be encountered by prospective lesbian, gay, and transgender foster and adoptive parents (Farr, Vazquez, and Patterson, 2020). Many uncertainties surround adoption as a pathway to parenthood for transgender individuals; only a handful of states prohibit discrimination against prospective parents who identify as transgender. Thus, transgender prospective adoptive parents may face added scrutiny.

Sexual and Gender Diverse Parenting and Children

The many studies that have examined parenting processes among SGD parents have found these family relationships to be generally warm and positive (Biblarz and Stacey, 2010; Goldberg, 2010; Golombok et al., 2014; Patterson, 1992, 2000, 2017). Both children and adolescents generally enjoy supportive relationships with lesbian and gay parents (Farr, Forssell, and Patterson, 2010a; Golombok et al., 2014; Wainright, Russell, and Patterson, 2004). Overall, and with some exceptions, both lesbian and gay couples seem to share child care and household labor more evenly than do heterosexual couples (Farr and Patterson, 2013; Patterson, Sutfin, and Fulcher, 2004). In contrast, research on small samples of the cisgender female partners of transgender men has shown that cisgender women report doing more household labor than their transgender male partners (Pfeffer, 2010); studies of child care in these couples have not been reported. Likewise, little information is available about parenting among those who identify as bisexual or intersex (Stotzer, Herman, and Hasenbush, 2014).

Many studies have focused on the development of children reared by lesbian and gay parents. Much of the research is focused on children with lesbian mothers (Goldberg, 2010; Golombok, 2015; Patterson, 1992, 2000, 2017), although some studies have also included children of gay fathers (Farr, Forssell, and Patterson, 2010a; Golombok et al., 2014, 2018; Tornello and Patterson, 2015). The research has focused on sexual and gender identity of children with LGBT parents, on peer relationships and other aspects of social development, academic performance, and overall adjustment (Farr, Forssell, and Patterson, 2010a; Farr et al., 2018; Farr and Patterson, 2013; Fedewa, Black, and Ahn, 2015; Golombok et al., 2014, 2018; Potter, 2012; Potter and Potter, 2016; Wainright and Patterson, 2008; Wainright, Russell, and Patterson, 2004). In general, across all characteristics, children of lesbian and gay parents have shown typical development (Manning, Fettro, and Lamidi, 2014; Patterson, 2017). At the same time, there is evidence that, when compared with children in heterosexual-parent families, children with lesbian parents report less pressure to conform to gender expectations and have more egalitarian attitudes regarding gender (Bos and Sandfort, 2010). Similarly, adult children of lesbian and gay parents report that they were raised with less rigid gender stereotypes than others (Goldberg, 2007). Regardless of their own sexual orientation, adult offspring of lesbian and gay parents report greater well-being when they live in social climates that are supportive for SGD people (Lick et al., 2012). Little information is available about children with bisexual, transgender, or intersex parents, but researchers have not identified special behavior problems of any kind among these children (Goldberg, 2010; Golombok, 2015; Patterson, 2000, 2017).

Much of the existing research has been based on relatively small convenience samples of participating families, leaving open questions about possible sample bias; this is especially true of early work (Patterson, 1992). Increasingly, however, research has been conducted using data from larger samples that are representative of the populations from which they were drawn, and this work has yielded findings that are similar to those from the earlier studies (Patterson, 2017). For example, data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) study (Wainright and Patterson, 2006, 2008; Wainright, Russell, and Patterson, 2004) and from the Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999 study (Potter, 2012; Potter and Potter, 2016) have produced findings that are consistent with those from earlier work. These studies drew on data from representative samples, so they do not reflect sample biases that are likely to be present in purposive and convenience samples.

Thus, after conducting a careful review of the research, in a resolution the American Psychological Association (2005) concluded:

Similarly, in its review of the literature, the American Sociological Association concluded that the clear and consistent social science consensus is that children reared by same-sex parents fare just as well as children reared by different-sex parents (American Sociological Association, 2015, p. 5).

Without question, however, multiple stressors, such as harassment and bullying, are often encountered by SGD parents and their children. The evidence clearly shows that children who are bullied by peers are more likely than other children to show behavior problems (Goldberg, 2010; Patterson, 2017). Some SGD-parent families also experience more economic stress, unemployment, and lack of health insurance relative to families headed by heterosexual parents (Patterson and Goldberg, 2016). Moreover, the experiences of offspring of SGD parents are influenced by the social climate in which they grow up (Golombok et al., 2018; Lick et al., 2012). The findings in this area suggest possible roles for law and policy in improving the lives of SGD parents and their children (see Chapter 5).

Other Family Ties

In addition to their roles as parents, SGD adults have other family ties, such as those with their own parents, siblings, and extended family. Of these, the relationships that have been studied most often are those between adult lesbian and gay people and their own parents. Overall, most researchers have reported that, on average, lesbian and gay adults have more distant, less positive relationships with their parents than do their heterosexual peers (Needham and Austin, 2010; Reczek, 2014; Tate and Patterson, 2019b; Ueno, 2005) and that this is a source of stress for many lesbian and gay adults. Research-based information about the relationships of bisexual and transgender adults and their parents and other members of families of origin is still scarce and often based on small, nonrepresentative samples (Brumbaugh-Johnson and Hull, 2018; Fredriksen-Goldsen et al., 2016; Norwood, 2013). In two studies using data from representative samples, however, indications of such stress have included depressive symptoms, substance use, and sleep problems (Patterson et al., 2018; Rothman et al., 2012).

A small number of studies have been conducted to assess variations across racial and ethnic minority groups with regard to relationships of SGD adults and members of their families of origin. For instance, Pastrana (2015) studied large samples of Black and Latinx SGM adults and found that disclosure of SGD identities (“outness”) was associated with support from members of the family of origin. In both Black and Latinx groups, those who had disclosed sexual and gender minority identities were more likely to feel supported (Pastrana, 2015); similar findings have been reported by Swendener and Woodell (2017). Among cisgender SGD Latinas, Acosta (2013) found that those who embodied conventional femininity were more likely to feel accepted by members of their families of origin. While these findings are important, they are not based on representative samples, and they do not allow comparisons across racial or ethnic groups. Additional research in this area would be valuable.

CLOSE RELATIONSHIPS IN ADULTHOOD

The most salient close relationships in adulthood are those with romantic partners, other family members (e.g., aging parents), and close friends. Close friends are sometimes referred to as one’s “chosen family” in SGD communities, in part due to weaker or more strained ties to one’s family of origin (Reczek, 2020). In this section we focus primarily on intimate and romantic relationships, which have been the focus of a great deal of research, and then highlight recent evidence concerning relationships with close friends and family.

Intimate and Romantic Relationships

Demographics and Relationship Status

Recent data from the Gallup Daily Tracking Survey indicates (Jones, 2017, cited in Goldberg and Romero, 2019, p. 3):

About 10.2 percent of the Gallup sample identified as being married to a same-sex spouse, and the number of married same-sex couples in the United States is growing—from 390,000 in 2015 to 547,000 in 2017 (Romero, 2017). Notably, over half of LGBT-identified people in the Gallup Tracking Survey are classified as single (see below, “Chosen Families”).

The legalization of same-sex marriage and more favorable societal attitudes towards same-sex coresidential relationships have likely contributed to the increased number of reported same-sex relationships (Gates and Brown, 2015). Same-sex couples are more likely than different-sex couples to be interracial and well educated (Gates, 2014) and to participate in the labor force (Gates, 2013). Women are also more likely than men to enter into same-sex relationships (Gates, 2014). Same-sex couples are more likely than different-sex couples to reside in urban areas (Gates, 2006) and in more LGBT tolerant regions of the United States, such as those where same-sex marriage was first legalized (Gates, 2009, 2014).

Romantic Partnerships and Health

There has been significant research on intimate partnerships of lesbian and gay populations, with most of the early research in this area focused on cohabiting relationships, civil unions, and domestic partnerships. This area of research expanded significantly to include attention to married same-sex couples when (as discussed above) the United States extended constitutional protection for marriage equality in 2015. In part, proponents of marriage equality argued that same-sex marriage recognition could improve the health of sexual minority adults and their children and that restriction from marriage was discriminatory and negatively affected health. A great deal of research has addressed the link between relationship status and health, and many of the findings rely on nationally representative and publicly available datasets.

Theoretical work on minority stress and gender-as-relational perspectives undergirds much of the influential research in this area. Minority stress theory points to the unique stressors and stigma associated with sexual minority status (LeBlanc, Frost, and Bowen, 2018), and gender-as-relational perspectives emphasize the different patterns of men’s and women’s partner interactions, depending on whether they are in a same- or different-sex union (Thomeer, Umberson, and Reczek, 2020). Higher levels of stress for sexual minority populations may mean that same-sex spouses encounter more stress in their daily lives in ways that strain their relationships and undermine their health. At the same time, marriage may be especially important in helping sexual minority populations to cope with stress and to protect their health and well-being.

Several studies on romantic partnerships and health of same-sex couples have relied on nationally representative data (e.g., data from the National Health Interview Study [NHIS]) and conclude that same-sex cohabiting couples’ health is worse than that of different-sex married couples but better than that of unpartnered adults (not differentiated by heterosexual/LGB status) (Denney, Gorman, and Barrera, 2013; Liu, Reczek, and Brown,

2013). Research suggests that greater legal recognition (i.e., marriages, civil unions, and registered domestic partnerships versus no legal status) is associated with better health and that same- and different-sex couples receive similar health benefits from marriage (LeBlanc, Frost, and Bowen, 2018).

There is much less research on bisexual, transgender, and intersex people in romantic partnerships. Growing evidence indicates that bisexual populations are in poorer health (on multiple measures, including mental health and functional limitations) than people who identify as gay, lesbian, or heterosexual (Bostwick et al., 2010; Conron et al., 2010; Fredriksen-Goldsen et al., 2010; Gorman et al., 2015; Hsieh and Ruther, 2016). One recent study, based on data from the NHIS, found that married persons who identify as bisexual report poorer health than their unmarried counterparts after adjusting for socioeconomic status and health behaviors (both of which are disadvantaged for bisexual respondents) (Hsieh and Liu, 2019). This study found a health advantage for married heterosexual partners and, to a lesser extent, men and women in same-sex partnerships, in comparison with their unmarried peers.

Hsieh and Liu (2019) also report that men and women who identify as bisexual in different-sex marriages are less healthy than those in same-sex marriages. The authors suggest that, although marriage may benefit the health of self-identified gay, lesbian, and heterosexual people, marriage may not benefit the health of those who identify as bisexual, perhaps due to higher levels of stigma and partner conflict associated with bisexuality. It is likely that individuals who identify as bisexual encounter unique sources of stress and stigma in their relationships (Feinstein and Dyar, 2017)—an important topic for future research. These findings also point to the importance of considering variation in romantic partnerships and health across diverse groups.

Current research on relationship status and health for couples in which at least one partner is transgender or gender-nonconforming is limited. With a few exceptions, the available evidence is descriptive and based on qualitative data drawn from small samples. This research has focused primarily on individuals who transition while in an existing relationship, and it addresses their specific challenges and supports. Emerging evidence suggests that an intimate partner relationship is a source of social and emotional support that can reduce perceived levels of discrimination for transgender people (Liu and Wilkinson, 2017; Pfeffer, 2016), suggesting potential health benefits. Liu and Wilkinson (2017) analyzed data from the National Transgender Discrimination study and found that married transgender women reported less discrimination than cohabiting and previously married transgender women (but not less than never-married transgender women). These patterns were partly explained by greater economic resources for married people. However, these patterns were not found for

transgender men. Taken together, these findings point to the importance of addressing variations as a function of gender identity and socioeconomic status, as well as race and ethnicity, in research.

Research on heterosexual populations shows that marriage becomes even more important to health with advancing age, as individuals develop health conditions, cognitive decline, or functional limitations. This finding may also emerge among aging sexual minority populations, but relevant research is not yet available. In a study of SGD adults over 50 years old, those who had a same-sex partner, regardless of marital status, reported better health and fewer depressive symptoms than those who were single (Williams and Fredriksen-Goldsen, 2014). Further study on aging and later-life SGD couples is needed, particularly longitudinal studies that allow researchers to follow couples as they grow older.

Relationship Dissolution

Longitudinal research on heterosexual populations clearly documents that marital dissolution through divorce or widowhood undermines health and well-being and increases mortality risk and that this effect is stronger for men than for women (Rendall et al., 2011). Much less is known about the effects of marital dissolution in SGD populations. The first book on this subject, published in 2019, represents a multidisciplinary effort to compile the current evidence (Goldberg and Romero, 2019), but study in this area is still quite new.

Divorce and Separation of Partners

Numerous studies have considered rates of relationship dissolution among same-sex couples. Manning and Joyner (2019) reviewed these studies and concluded that, across same-sex and different-sex couples, dissolution rates for married and cohabiting couples are fairly similar; cohabiting couples show higher rates than do married couples. Moreover, cohabiting same-sex female couples have higher probabilities of relationship dissolution than same-sex male couples (Manning and Joyner, 2019). Both for same- and different-sex couples, legally recognized relationships are characterized by greater stability.

Several factors have been associated with higher rates of relationship dissolution among SGD populations, especially among female same-sex couples. Joyner and colleagues (2017) analyzed Add Health data and found that, for young adults, racial minority status and lower socioeconomic status increase marital instability for same-sex couples, much as it does for different-sex couples. Transgender people may also be at greater risk for marital instability, particularly for those who married prior to transition. Meier and colleagues (2013) report that, among transgender men who were partnered prior to transition, half of the relationships were dissolved during or after transition. Again, relatively few data are available in this area.

Widowhood (Death) of a Partner

Very little is known about the bereavement experiences of sexual minority populations following the death of a partner. Notably, the landmark case leading to marriage equality, Obergefell v. Hodges, was based on the inability of a bereaved spouse to be listed on the death certificate of his partner (thus, disallowing spousal benefits granted to different-sex spouses). Many of the existing studies of partner bereavement in sexual minority populations (primarily gay men) are focused on death of partners due to HIV-related causes; these studies have found increased social isolation, risky sexual behavior, and mental health problems during the bereavement process (Hatzenbuehler, Nolen-Hoeksema, and Erikson, 2008; Rosengard and Folkman, 1997; Satterfield, Folkman, and Acree, 2002). Additional work on bereavement following loss of a partner is needed, including the possibility of unique bereavement experiences of SGD populations (compared with different-sex couples) due to differences in marital dynamics, the presence or absence of children, family support, and sexual or gender minority stressors (Donnelly, Reczek, and Umberson, 2018). Indeed, results of available studies of bereavement in sexual minority populations due to non-HIV-related causes suggest that sexual minority populations face bereavement experiences that are shaped by the quality of interactions with health care providers prior to a partner’s death and also by more complex legal and financial issues than those experienced by different-sex couples (Bristowe, Marshall, and Harding, 2016).

Relationship Dynamics, Health, and Well-Being

The accumulation of daily experiences and partner interactions in couples influences health and well-being over time. Partners may help each other to cope with stress, yet partners can also be a source of stress. There is a large research literature on relationship dynamics of different-sex couples: findings from this literature describe how cohabiting, marital, and other committed partnerships contribute to or detract from health and well-being. Information is, however, much more limited for SGD populations; the available evidence suggests certain types of variation in relationship dynamics and health for men and women in same-sex relationships in comparison with different-sex relationships (Umberson and Thomeer, 2020). The rest of this section highlights some of the key relationship dynamics known to be important for couples: overall relationship quality, sexual minority stress, division of labor, the dynamics of sexual and emotional intimacy, intimate partner violence, partners’ influences on health behaviors, and caregiving dynamics when a partner is ill.

Overall Relationship Quality

Much of the research on SGD couples has focused on partner interactions and relationship quality. The preponderance of evidence suggests that same-sex and different-sex couples are

similar in overall relationship quality, such as closeness and emotional support (Farr, Forssell, and Patterson, 2010b; Kurdek, 2005).

Sexual Minority Stress

Although it is well established that sexual minority stress adversely affects the health of individuals (Hatzenbuehler et al., 2012), a growing research literature has also explored the ways in which sexual minority stress affects couples (Frost et al., 2017; LeBlanc, Frost, and Wight, 2015). This approach emphasizes that individuals in SGD couples may be vulnerable to couple-level minority stressors that cannot be understood in individual terms (Neilands et al., 2019). These stressors may include lack of integration with families of origin, management of stereotypes about their relationships, and couple-level experiences of discrimination (Neilands et al., 2019). Spouses or partners can also play an important role in helping each other cope with minority stress. In fact, relationships can help to buffer individuals from adverse effects of minority stress (Cao et al., 2017; Donnelly, Robinson, and Umberson, 2019). Members of the couple’s families of origin may also affect romantic relationships. When parents are critical of a partner or of a relationship, it can impose strain on couple relationships; however, the joint efforts of couples to cope with this kind of stress can also promote resilience (Frost, 2011; Graham and Barnow, 2013; Macapagal et al., 2015; Reczek, 2016).

Division of Labor

Considerable research has been conducted on the division of household and child care labor in same-sex partnerships. The preponderance of evidence has shown that same-sex couples are more egalitarian in their division of household and child care than are different-sex couples (Patterson, Sutfin, and Fulcher, 2004). However, much of this research focuses on small, nonrepresentative samples of predominantly white lesbian and gay couples. There may be important variations across racial and ethnic and socioeconomic statuses, and these may covary with family structure (Moore, 2011), so it is difficult to draw clear general conclusions at this time (Patterson, Sutfin, and Fulcher, 2004). Qualitative research on families of transgender people (Pfeffer, 2016; Ward, 2010) suggests that cisgender women coupled with transgender men do comparatively more housework in an effort to clarify and assert gender order.

Dynamics of Sexual and Emotional Intimacy

Studies based on national samples indicate that overall satisfaction with sex is similar for those in gay, lesbian, and heterosexual couples (Holmberg and Blair, 2009; Kurdek, 1991; Peplau and Fingerhut, 2007). Gay couples report less sexual exclusivity (Joyner, Manning, and Prince, 2019) and more frequent sexual encounters of shorter duration than do lesbian couples, but no differences in sexual satisfaction (Blair and Pukall, 2014; Farr, Forssell, and Patterson, 2010b). Qualitative data suggest that same-sex partners (both male and female) are more concordant than different-sex partners in their levels of sexual desire and views of intimacy. Lesbian women are more concerned

with and do more work to promote sex in their relationships than do gay men, possibly because they are more likely to see sex as indicative of intimacy, closeness, and relationship quality (Umberson et al., 2015).

Intimate Partner Violence

The available evidence, limited by the few studies that rely on representative data, indicates that the incidence of intimate partner violence in LGB couples is similar to or greater than that in heterosexual couples (Edwards, Sylaska, and Neal, 2015; Rollè et al., 2018). Notably, intimate partner violence is more likely in cohabiting couples than in marital relationships, and it is especially prevalent among bisexual individuals (National Intimate Partner and Sexual Violence Survey, 2010). The risk factors for intimate partner violence are also similar for heterosexual and LGB partners and include lower socioeconomic status, being younger, substance use disorders, and exposure to family violence as a child (Edwards, Sylaska, and Neal, 2015). In addition, unique risk factors have been observed for LGB populations, including sexual minority stress, internalized homonegativity, and the failure of community and health care systems to identify and treat intimate partner violence in SGD populations (Edwards, Sylaska, and Neal, 2015; Rollè et al., 2018). (See Chapter 11 for additional studies of LGBTQ victimization.)

Partners’ Influences on Health Behaviors

Spousal influence on health behaviors is often identified as one reason for the better health status of married different-sex couples compared to their unmarried counterparts (Rendall et al., 2011). Only recently have researchers had access to data that clearly identified the union status of SGD individuals. Although patterns of health behavior in different-sex marriages often differ for men and women (e.g., men are more likely than women to drink heavily), health behaviors in same-sex marriages seem to be characterized by more similarity between spouses. A recent study of more than 400 couples using dyadic data shows that same-sex spouses are more similar to one another than are different-sex spouses in their smoking, drinking, and exercise habits (Holway, Umberson, and Donnelly, 2018); results of this study showed greater concordance for lesbian than for gay spouses. Exactly how same-sex spouses influence one another’s health and well-being, and how that influence may evolve over the life course, is a topic for future study.

Caregiving Dynamics When a Partner Is Ill

Spouses are typically the front line of defense when an adult becomes ill, and spouses who provide informal care or facilitate formal health care for their partners may promote the partner’s health and well-being—even while caregiving may impose stress on the caregiver. One study of interview data from 90 spouses (45 couples) considered how spouses co-construct illness experiences in ways that shape relationship dynamics (Umberson et al., 2016). In both same- and different-sex marriages, men tend to downplay illness

and thus perform less care work when their spouse is ill; women tend to construct illness as involving intensive care work (Umberson et al., 2016). Same-sex spouses described similar constructions of illness more often than different-sex couples and, as such, same-sex spouses described less illness-related disagreement and stress around caregiving (Umberson et al., 2016).

These qualitative findings are supported by dyadic survey data from more than 800 respondents who reported on couples’ behavior during serious illness events (Umberson et al., 2017). Women tended to provide and receive more instrumental care than men; women who were married to women provided and received the most instrumental care. Men and women in same-sex marriages reported providing more emotional support for their sick spouse than did men and women in different-sex marriages. However, during their own health event, women—whether they were married to a man or a woman—provided more emotional support to their spouse than did men. These findings point to the many similarities in caregiving across union types and suggest that differences across union types reflect the intersection of gender and sexuality.

There may be a greater need for caregiving in SGD than in heterosexual communities due to higher levels of certain chronic conditions, poorer overall health, and higher risk of cognitive impairment (Baumle, 2014; Fredriksen-Goldsen et al., 2018). Because SGD people are less likely than others to have a spouse or partner and less likely to have children, those who need care may also face unique challenges in getting that care. Members of families of origin who do not accept SGD identities may create additional strains in this regard. Both SGD caregivers and SGD care recipients may face challenges in obtaining needed services and medical care, in that the legacy of stigma and discrimination in institutional settings contributes to underutilization of medical and social services for older LGBT adults (SAGE, 2014).

Very little is known about end-of-life experiences for SGD couples and families (Marsack and Stephenson, 2018; Reczek, 2020). One small-scale qualitative study found that lesbian and gay couples were more likely than heterosexual couples to plan for their end of life (e.g., by having wills and related documents), in part because same-sex couples were more concerned about possible interference from members of their families of origin due to their sexual minority status (Thomeer et al., 2017). Now that marriage equality is the law, this situation may shift, but little is yet known about this possibility.

Overall, and apart from studies of caregiving within intimate relationships, little is known about illness and caregiving among adult or aging SGD populations (Reczek and Umberson, 2016), and there are even fewer studies of end-of-life issues among SGD people. A few studies suggest dif-

ferences in caregiving needs and experiences of SGD people in comparison with other older people, but little is yet known about this topic. These are areas of research in need of further study.

Chosen Families

Marital and romantic partnerships are clearly important to the health and well-being of SGD as well as heterosexual populations, but more than half of LGBT-identified people were classified as single in recent Gallup tracking surveys (Romero, 2017). Moreover, SGD adults report less frequent contact and more strain in their family-of-origin relationships than do heterosexual adults (Reczek, 2020). Several types of evidence suggest that, compared with their heterosexual counterparts, SGD people rely more on support from “chosen families”—selected friend and social network ties.

Recent evidence on the function and composition of support networks reveals considerable complexity. Using data from a community study of 524 lesbian, gay, bisexual, and heterosexual adults living in New York City, Frost and colleagues (2016) reported that, although heterosexual and LGB individuals relied more on friends than families of origin for routine support (e.g., talking about problems), gay and bisexual men relied more on friends than did lesbian and bisexual women. For major support (such as borrowing money), heterosexual people and lesbian and bisexual women relied mostly on members of their families of origin, whereas gay and bisexual men relied more on friends. Frost and colleagues (2016) found additional variation based on race and ethnicity—with racial and ethnic minority SGD individuals reporting less overall support than others. These findings, like those concerning romantic and marital relationships, point to the need for future research to consider the intersection of gender and sexuality, as well as race and ethnicity, in understanding the relationship dynamics that influence health and well-being in potentially different ways across SGD groups.

Chosen families may also play an important role in caregiving in SGD communities. In one study, for example, in contrast to the 6 percent of heterosexual older adults who reported providing care to a friend, 21 percent of older LGBT adults reported having provided care to friends (MetLife Mature Market Institute and American Society on Aging, 2010). Another survey of American adults (Robbins et al., 2017) found that LGBTQ adults were more likely than others to have taken time off from work to care for someone in their chosen family. Although friends who provide care may experience caregiving stress and psychological distress associated with that caregiving (Shiu, Muraco, and Fredriksen-Goldsen, 2016), this care is valuable in supporting the independence, health, and well-being of the SGD recipients of that care.

SUMMARY AND CONCLUSIONS

Close, supportive, and stable relationships foster health and well-being, and relationships early in life have implications for the quality and stability of social ties in adolescence and adulthood. Many SGD and intersex people are coming out at younger ages than in previous years, and this affects their social relationships. SGD youth are at higher risk of depressive symptoms, anxiety, and suicidality than other youth. In addition, many SGD youth encounter harassment and hostility at home or at school, which can have negative effects on their mental and physical health.

Supportive family relationships are a foundation for child and adolescent well-being for SGD as for other people. Parental acceptance of their SGD youth is associated with positive youth adjustment; conversely, parental rejection is associated with a range of emotional and behavioral health problems. Supportive teachers are among the most important nonfamily adults in the lives of contemporary SGD youth. Maintaining friendships throughout and following the coming out process supports positive adjustment for SGD youth. Romantic relationships in youth are also supportive in many cases, although the risk of intimate partner violence is higher for SGD youth than for other youth.

Further research is needed on developmental processes among SGD youth as well as on the effects of intersectional identities, stigma, and discrimination on developmental processes. Study is especially needed on bisexual, transgender, and intersex youth.

The number of married same-sex couples has nearly doubled since 2015. There is much more evidence on union status and health of gay and lesbian couples than on that of other SGD populations. Higher levels of stress for sexual minority populations may mean that same-sex spouses encounter more stress in their daily lives in ways that strain their relationships and undermine their health. At the same time, marriage may be especially important in helping sexual minority populations to cope with stress and to protect their health and well-being. The legal status of romantic unions is associated with other markers of advantage and disadvantage, particularly socioeconomic status. Those of higher socioeconomic status are more likely to marry, and marriage itself may also provide economic benefits. As with different-sex couples, legally recognized same-sex relationships are less likely than others to dissolve over time.

The existing evidence is characterized by sample and research design limitations. To clarify links between union status and health, longitudinal data with well-validated measures of sexual and gender identity are needed.

Lesbian, gay, and intersex individuals are less likely than heterosexual individuals to become parents. Less is known about the prevalence of parenthood among bisexual and transgender people. Some SGD people become parents in the context of prior heterosexual relationships—a pathway that is more common for older people than younger people. Another pathway to parenthood among LGBTQ+ people involves the use of assisted reproductive technology; however, the costs of such techniques can be high, so access to these options is limited to those with substantial financial resources. Some SGD adults also become foster or adoptive parents. Both children and adolescents have been found to enjoy supportive relationships with lesbian and gay parents, and children of lesbian and gay parents have shown typical development.

In contrast to the evidence about lesbian and gay parents, less is known about parenting by bisexual or transgender people, but existing research suggests that they are as competent in parenting roles as other parents. Additional research is needed on relationship development in adolescence, adult family formation among SGD (especially bisexual, transgender, and intersex) people, as well as family processes and couple dynamics among older SGD individuals and families.

Throughout adulthood, people who are more socially connected have better mental and physical health and lower mortality than those who are more socially isolated. Evidence suggests that SGD adults rely more on support from friends and “chosen families” than do their heterosexual counterparts. In comparison with heterosexual peers, SGD adults report less frequent contact and more strain in their family-of-origin relationships. Overall, lesbian and gay adults report more strained relationships with their own parents than do heterosexual adults, and these strained relationships are associated with stress, psychological distress, and unhealthy behaviors.

Friends and members of chosen families may also play an important role in SGD communities. For example, many more LGBT than heterosexual older adults reported providing care to a friend. This care is invaluable in supporting the independence, health, and well-being of SGD care recipients.

Research is needed on the effects of relationships on SGD well-being that uses reliable assessment tools, samples that are based on nationally representative data, and longitudinal designs. Research on SGD families and couples that devotes attention to diversity and intersectionality, with a particular focus on multiple, intersecting forms of inequality, is also needed.

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