11

Physical and Mental Health

Since the Institute of Medicine report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (2011), the published literature on the physical and mental health of sexual and gender diverse (SGD) populations has expanded substantially. Recent research emphasizes the complexity of the multilevel and intersecting factors that influence the well-being of SGD people and drive disparities in health status, health care access, and health outcomes in SGD populations. These drivers include stigma; minority stress exposures, such as discrimination; and other behavioral, environmental, and structural risk factors. The intensity and effects of drivers of disparities can vary across the life course and among different SGD communities on the basis of factors such as race, age, and gender. Research has also begun to underscore, however, the degree to which resilience and effective interventions can mitigate health risks and help reduce these disparities.

This chapter reviews the literature on physical and mental health in SGD populations in the United States, identifies major group differences, describes drivers of disparities, and highlights opportunities for interventions to address these disparities. It is outside the scope of this report to assess SGD population health in international contexts, though this is an important area of scholarship. The chapter covers physical health, with a focus on general well-being, health behaviors, cardiovascular disease, and cancer; reproductive and sexual health, including fertility; violence and victimization; and mental and behavioral health. Although these topics are addressed individually to highlight the specific evidence for each, it is important to note that they are deeply intertwined and share cross-cutting

influences, such as minority stress and systemic barriers to health care services. Research and interventions to understand and improve the health and well-being of SGD populations need to reflect these complex relationships while also seeking to clarify how both disparities and resilience uniquely manifest in specific groups within the SGD population.

Following this chapter, Chapter 12 looks at SGD population health in the United States in the context of health care access and utilization, with a focus on the importance of SGD people having access to adequate insurance coverage; culturally competent providers; and high-quality, evidence-based health care services, including gender-affirming care for transgender and non-binary people. It also discusses the challenges posed by the continued prevalence of two medical approaches to SGD populations that are not evidence based: unnecessary genital surgeries for children with intersex traits and conversion therapy targeting sexual orientation or gender identity.

The information presented in these two chapters reflects both the current body of research and a multidimensional understanding of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization [WHO], 1948). Health is central to well-being and quality of life for all people, but it is not equally distributed across populations. Health disparities are preventable differences in the burden of disease, morbidity, mortality, or opportunities to achieve optimal health. They are associated with a range of social, economic, and political determinants that are dynamic manifestations of the systems that distribute resources, protection, and power across society (Braveman et al., 2017). These determinants affect health by conferring social, economic, or political advantage on certain population groups, while limiting the resources available to members of disadvantaged groups for maintaining and improving their health and well-being. These determinants also mediate exposure to physical and mental health hazards, such as stigma, violence, discrimination, unhealthy environments, and inadequate medical care (Marmot et al., 2008; WHO, 2008). Health disparities thus represent the human embodiment of disadvantage and inequality in the daily conditions in which SGD people grow up, form families, work, age, and die (WHO, 2011).

Consideration of the social determinants of health introduces a moral and ethical dimension, frequently termed “health equity,” into discussions of disparities. Health equity means that everyone should have a fair and just opportunity to be as healthy as possible, and it underscores that health disparities are avoidable and, therefore, unjust and unjustifiable (Braveman et al., 2017). Achieving health equity requires eliminating disparities by removing obstacles to good health such as discrimination, stigma, and their consequences. Health equity thus places an implicit

responsibility on policy makers, researchers, health care providers, advocates, and other stakeholders for accountable efforts to improve the health and well-being of populations experiencing disparities.

PHYSICAL HEALTH

General Health and Well-Being

Studies of general health and well-being have revealed that LGBTI adults tend to report worse health, lower health-related quality of life, and greater prevalence of disabilities than non-LGBTI people (Baker, 2019; Charlton et al., 2018; Fredriksen-Goldsen et al., 2013; Gates, 2014; James et al., 2016; Lett, Dowshen, and Baker, 2020; Meyer et al., 2017; Potter and Patterson, 2019; Rapp et al., 2018; Streed et al., 2017; Ward et al., 2014). Disparities in overall health have been found to be particularly substantial for bisexual and transgender people, especially non-binary people (Downing and Przedworski, 2018; Dyar et al., 2019, 2020; Lefevor et al., 2019). Emerging identity groups, such as asexual and pansexual populations, also appear to experience disparities in overall health and well-being (Borgogna et al., 2019; Yule, Brotto, and Gorzalka, 2013). In terms of mortality, there are only a few studies that focus on sexual orientation or gender identity, and none on intersex status. The studies that exist, however, report that mortality may be higher in LGBT than in non-LGBT populations (Asscheman et al., 2011; Asscheman, Gooren, and Eklund, 1989; Blosnich et al., 2014; Cochran, Björkenstam, and Mays, 2016; Cochran and Mays, 2011; Cochran and Mays, 2015; Dhejne et al., 2011; van Kesteren et al., 1997; Wiepjes et al., 2020).

Drivers of General Health and Mortality Disparities

The literature around both general well-being and mortality in SGD populations emphasizes the degree to which stigma and minority stress related to sexual orientation and gender identity (and presumably intersex status as well, though there is no research in this area) are important influences on these disparities (Gonzales and Ehrenfeld, 2018; Russo et al., 2012; Solazzo, Brown, and Gorman, 2018; Streed, McCarthy, and Haas, 2017). Physiologically, minority stress exposures contribute to the dysregulation of cortisol, which adversely affects metabolism, immune function, cardiovascular health, cognition, and mood (Berger and Sarnyai, 2015; DuBois et al., 2017). Minority stress is also associated with higher prevalence of unhealthy behaviors, such as tobacco use and binge drinking, and it is a risk factor for causes of mortality that include HIV and suicide. More research is needed to accurately measure minority stress exposures in SGD

populations and to investigate the origins, pathways, and consequences of minority stress for all aspects of health and life expectancy.

Bisexual health disparities, like other SGD health disparities, are often driven by stigma and minority stress (Doan Van et al., 2019; Friedman et al., 2014; Katz-Wise, Mereish, and Woulfe, 2017). While disparities related to minority stress can be buffered by social support, bisexual individuals report lower access to such support both within and outside of sexual minority communities, and they often report feeling socially isolated, invisible, and marginalized in both heterosexual and LGB communities (Meckler et al., 2006; Mulick and Wright, 2011; Saewyc et al., 2009; Yost and Thomas, 2012). Studies have found unfavorable attitudes toward bisexual people among gay and lesbian people as well as among heterosexual people (Dodge et al., 2016). A study using a feeling thermometer technique found that heterosexuals viewed bisexual people less favorably than all other comparison populations (including gays and lesbians and various religious, racial, and political groups) except for injection drug users (Herek, 2002).

For SGD Native American, Black, and other people of color, general health and mortality are additionally affected by exposure to racism. Native Americans, Native Hawaiians and other Pacific Islanders, and Alaska Natives, for example, have experienced centuries of trauma that includes affronts to their cultures and the systematic disruption and destruction of their communities through massacres, transmission of non-Indigenous infectious diseases, and forced migration and assimilation (Brave Heart and Debruyn, 1998; Kirmayer, Gone, and Moses, 2014; Walters and Simoni, 2002; Walters et al., 2011). Trauma from historical slavery and current structural violence, such as police brutality and high rates of incarceration, has similarly had pervasive negative effects on the physical and mental health of Black people (Chae et al., 2020; Williams, 2018). Historical trauma can transmit risk for poorer health and well-being to future generations by depleting psychological resilience and eroding supportive family, community, and economic structures.

Transgenerational transmission of stress- and trauma-related health risks can also occur through inherited epigenetic DNA modifications or in utero maternal-fetal exposure (Conching and Thayer, 2019; Walters et al., 2011). SGD people of color may experience the unique stressors of both racism and ethnocentrism in white SGD communities and rejection of their sexual orientation or gender identity by their racially or ethnically congruent families and communities (Hatzenbuehler, Phelan, and Link, 2013; Isasi et al., 2015; Pascoe and Smart Richman, 2009; Valdiserri et al., 2018; Worthen, 2018). They may therefore face health risks and disparities that differ from and may exceed those facing either white SGD communities or heterosexual and cisgender communities of color (Lett, Dowshen, and Baker, 2020; Tuthill, Denney, and Gorman, 2020).

Interventions to Improve Overall Health and Resilience

Resilience, a process that confers the ability to recover from or adjust to adversity, is an important counterweight to the effects of minority stress on general health and mortality in SGD populations. Studies conducted with a variety of SGD populations indicate that identity affirmation (Fredriksen-Goldsen et al., 2017; Matsuno and Israel, 2018), social support (Baratz, Sharp, and Sandberg, 2014; Sani et al., 2019; Schweizer et al., 2017), family acceptance (Katz-Wise, Rosario, and Tsappis, 2016), and protective laws and policies (Hatzenbuehler and Keyes, 2013; Hatzenbuehler et al., 2014) are associated with positive coping and resilience. Most of the research on resilience interventions has focused on youth. This research provides strong evidence for the role of school-based gay-straight alliances in promoting resilience among LGBTQ youth (Davis, Royne Stafford, and Pullig, 2014; Johns et al., 2019a; Poteat, Calzo, and Yoshikawa, 2016; also see Chapter 9). As of this writing, at least one comparative effectiveness research trial is under way to assess resilience to depression among racial and ethnic minority SGD populations (Vargas et al., 2019). More research is needed to identify effective interventions to promote SGD population resilience.

Health-Related Behaviors

Behavior patterns related to sleep, diet, exercise, and smoking are important determinants of health and well-being. When sleep is inadequate, for instance, people have more illnesses and accidents, and they suffer more chronic mental and physical health problems (Grandner and Pack, 2011; Walker, 2017). Results of recent studies suggest that sleep difficulties, such as reduced sleep duration and lower sleep quality, are more common among LGBT people than among heterosexual and cisgender people (Chen and Shiu, 2017; Cunningham, Dai and Hao, 2017; Harry-Hernandez et al., 2020; Kann et al., 2016; Patterson and Potter, 2019; Patterson et al., 2018; Xu, and Town, 2018). These findings are not completely consistent, however, suggesting that important patterns of disparities may be elucidated by more research on specific groups such as youth and transgender people. There is no evidence about sleep health among people with intersex traits.

Similarly, the evidence about diet and exercise in SGD populations is not entirely consistent. Some studies have found that sexual minority boys and girls were more likely than heterosexual youth to report low intake of fruit and vegetables (Rosario et al., 2014). Others have found no differences by sexual orientation (Boehmer et al., 2012; Laska et al., 2015), and some data suggest that the diets of sexual minority adults are as good as or pos-

sibly better than those of heterosexual individuals (VanKim et al., 2017). Likewise, a number of studies have found that sexual minority youth of all genders are less likely than their heterosexual peers to participate in team sports or regular physical activity (Calzo et al., 2014; Laska et al., 2015; Mereish and Poteat, 2015), while other studies show disparities in exercise habits for some gender or age groups but not for all (Boehmer et al., 2012; Rosario et al., 2014).

Cigarette smoking, by contrast, is clearly elevated among LGBT populations. The National Health Interview Survey found that 21 percent of lesbian, gay, or bisexual adults reported being current cigarette smokers, compared with 15 percent of heterosexual adults (Jamal et al., 2018). Smoking prevalence is also higher among transgender populations (Buchting et al., 2017; Hoffman et al., 2018). Smoking is a major risk factor for numerous diseases and conditions, including pulmonary and cardiovascular diseases, cancer, type 2 diabetes, periodontal disease, adverse pregnancy outcomes, and visual loss and blindness (Centers for Disease Control and Prevention [CDC], n.d.).

Drivers of Health Behavior Disparities

The minority stress theory suggests that disparities in sleep, diet, exercise, and smoking among SGD populations are related to experiences of chronic stress due to stigma and discrimination. It is well known that stress exacerbates sleep difficulties, such as insomnia (Akerstedt, 2006). Peer bullying and structural discrimination, such as laws barring transgender youth from participating in school sports, may discourage adolescents from participating in organized sports (Buzuvis, 2016; Cunningham, Buzuvis, and Mosier, 2018; Douall et al., 2018). Consumption of healthy foods, such as fruits and vegetables, is related to access to economic resources at both the household and neighborhood levels, making poverty and employment discrimination key covariates in investigations of diet among SGD populations (French et al., 2019). In addition to stigma and discrimination, risk factors for cigarette smoking among LGBT people include targeted tobacco marketing, lack of access to smoking cessation programs and treatments due to poverty and lack of health insurance, and a lack of cultural competency in smoking cessation programs (Jamal et al., 2018). For transgender people, a lack of access to gender affirmation is also associated with smoking and other health risk behaviors (Menino et al., 2018). Further study is needed on the drivers of health behaviors related to sleep, diet, exercise, and smoking, especially among SGD adolescents and older adults, transgender people, and people with intersex traits.

Interventions to Improve Health Behaviors

A variety of tailored 12- to 16-week interventions for overweight lesbian and bisexual women have included weekly group meetings, nutrition education, and physical activity support, with or without additional components of mindfulness, gym membership, and pedometer use. These tailored interventions have resulted in significant improvements in multiple health behaviors and health indicators, including physical activity, weight, and waist-to-hip ratio (Rizer et al., 2015). Key characteristics of health behavior interventions for sexual minority women include social support, education and goal setting, peer facilitation, and LGBT-friendly environments (Berger and Mooney-Somers, 2017).

Evidence of the efficacy of smoking cessation interventions for LGBT adults exists for community-wide smoke-free policies (Wintemberg et al., 2017), quit-smoking group-based interventions with or without pharmaceutical components (Eliason et al., 2012; Matthews et al., 2019), web-based interventions (Heffner et al., 2020), and social branding campaigns (Fallin et al., 2015). While LGBT-tailored programs are often preferred by LGBT participants, non-tailored programs can demonstrate similar efficacy (Grady et al., 2014). Promising interventions currently under study include tailored social media and app-based smoking cessation interventions for sexual and gender minority youth (Baskerville et al., 2016; Vogel et al., 2019).

Cross-sectional studies suggest that increased access to legal (e.g., gender-congruent identity documents) and medical (e.g., hormone therapy) gender affirmation and decreased exposure to structural discrimination may reduce smoking and increase physical activity among transgender adults (Jones et al., 2018; Myers and Safer, 2017; Shires and Jaffee, 2016). More research is needed into effective interventions to optimize health behaviors among SGD populations, particularly since interventions designed to improve such health behaviors as sleep, diet, exercise, and smoking have important influences on other areas of health that are discussed in more detail below, such as cardiovascular disease and cancer.

Cardiovascular Disease

Some studies have found no difference between groups such as heterosexual adults and gay and bisexual men in cardiovascular disease (CVD) (Fredriksen-Goldsen et al., 2013). A growing body of evidence, however, indicates that LGBTI populations do experience CVD disparities, including elevated prevalence of coronary artery disease and angina and greater incidence of myocardial infarction and stroke (Alzahrani et al., 2019; Caceres, Veldhuis, and Hughes, 2019;

Caceres et al., 2017, 2018, 2019a, 2019b; Donato and Ferreira, 2018; Falhammar et al., 2018; Gonzales and Henning-Smith, 2017; Gonzales, Przedworski, and Henning-Smith, 2016; Hatzenbuehler, McLaughlin, and Slopen, 2013; Lagos, 2018; Lunn et al., 2017; Meads et al., 2018; Operario et al., 2015; Reisner et al., 2016a; Salzano et al., 2016, 2018; Silberbach et al., 2018; Streed et al., 2017). These disparities are greatest among bisexual compared to monosexual people, transgender compared to cisgender people, and Black compared with white lesbian women (Caceres, Veldhuis, and Hughes, 2019). One study also reported that gender-nonconforming individuals may have higher prevalence of coronary artery disease and greater incidence of myocardial infarction than either cisgender or transgender men and women (Downing and Przedworski, 2018).

Drivers of Cardiovascular Disparities

Disparities in CVD are driven by the greater prevalence in SGD populations of risk factors that include smoking, high blood pressure, and elevated levels of C-reactive protein, a biomarker of stress-related inflammation important in the pathogenesis of CVD (Hatzenbuehler, McLaughlin, and Slopen, 2013). Among sexual minority women and bisexual men, metabolic syndrome, which can include signs of insulin resistance, is also a common CVD risk factor (Caceres et al., 2018; Cunningham, Xu, and Town, 2018). As is the case for general health and mortality, many CVD risk factors in SGD populations are related to trauma and other minority stress exposures (Caceres et al., 2019a, 2019b; Rosengren et al., 2004; Sinclair and Wallston, 2004; Yusuf et al., 2004).

CVD risk among people with intersex traits varies by type of intersex trait as well as by experiences with hormonal and surgical therapies (El-Maouche, Arlt, and Merke, 2017; Los et al., 2016 Mooij et al., 2017). The cardiovascular effects of long-term hormones prescribed after gonadectomy are poorly understood (Gomez-Lobo and Amies Oelschlager, 2016). Hormone therapy similarly effects CVD risk among transgender people. Transgender women on estrogen therapy have increased risk of venous thromboembolism compared with cisgender people and transgender men (Dutra et al., 2019; Getahun et al., 2018; Gooren and T’Sjoen, 2018; Irwig, 2018; Quinn et al., 2017), and some studies suggest increased risk for myocardial infarction as well (Connelly et al., 2019). In transgender men, testosterone therapy is associated with elevated prevalence of CVD risk factors such as hypertension, insulin resistance, and dyslipidemia, though not with increases in CVD or mortality (Streed et al., 2017).

Interventions to Improve Cardiovascular Health

Most intervention research on prevention of CVD among SGD populations has focused on smoking cessation among LGBT adults, weight management among sexual minority women, and the benefits versus risks of hormonal therapies among people with intersex traits. Weight management and smoking interventions are discussed above in the section on health behaviors. Data on efficacy of CVD interventions for people with intersex traits are sparse, but several studies suggest early and regular screening and treatment for CVD risk factors such as hypertension and pre-diabetes among groups with elevated risk (Davis and Geffner, 2019; Los et al., 2016; Tamhane et al., 2018).

Cardiovascular health research priorities for SGD populations include the routine use of standardized measures of sexual orientation, gender identity, and intersex status in CVD research studies, especially longitudinal studies; studies that use objective measures of CVD (e.g., biomarkers and electronic health record data) rather than purely self-reported data; and rigorous study designs to investigate the relationship between hormone therapy and CVD risk and outcomes for transgender people and people with intersex traits (Caceres, Brody, and Chyun, 2016). Research is also needed into the impact of and interventions to address intersectional minority stress exposures as risk factors for CVD in SGD populations (Veenstra, 2013).

Cancer

In 2019, the American Cancer Society estimated that 130,000 LGBTQ people were newly diagnosed with cancer, and 45,000 died of cancer. These estimates were derived by applying the estimated percentage of the U.S. population that is LGBTQ to the 2019 projected cancer incidence in the general population. More accurate statistics about the overall prevalence and incidence of cancers among LGBT, intersex, and other SGD populations are precluded by the fact that health care systems, cancer registries, and national repositories of cancer data do not yet routinely capture demographic information about sexual orientation, gender identity, or intersex status (Gomez et al., 2019). Also lacking are population-based prospective studies evaluating cancer-specific risks, mortality, and survivorship issues facing SGD populations (Boehmer, 2018; Kent et al., 2019).

Existing data do suggest, however, that the incidence of certain cancers may be elevated in specific LGBTI populations. These include, for example, anal cancer in gay and bisexual men and breast cancer in lesbian and bisexual women (Quinn et al., 2015). The lifetime risk of germ cell tumors varies considerably across intersex conditions (Pyle and Nathanson, 2017), and gonadal cancers have been associated with

a variety of intersex conditions (Gomez-Lobo and Amies Oelschlager, 2016). Despite a low risk of gonadal malignancy before puberty, many intersex people have unnecessary gonadectomy in childhood (see discussion in Chapter 12), which means the risks for some cancers in people with intersex traits are unknown.

Drivers of Cancer Disparities

Elevated rates of cancer in SGD populations result from complex interacting risk factors. These factors can be sociodemographic, such as education and age; economic, such as employment and insurance coverage; environmental, such as food, second-hand smoke exposure, and environmental pollution related to health services, such as access to recommended care and providers’ levels of cultural and clinical competency in caring for SGD populations; and individual, such as genetics, birth parity, alcohol and tobacco use, and history of sexually transmitted infections. For example, use of alcohol and tobacco, as well as rates of HIV, human papilloma virus (HPV), and hepatitis C infections, are higher in some LGBT populations than non-LGBT populations, which increases the risk of lung, breast, colorectal, and other cancers associated with these exposures (Herbst et al., 2008; Hughes et al., 2017; Lee, Griffin, and Melvin, 2009).

Evidence also indicates that access to cancer-related preventive services is lower in LGBT populations than other populations, which leads to many missed opportunities for primary and secondary cancer prevention (Cathcart-Rake, 2018; Ceres et al., 2018). For example, lesbian and bisexual women are less likely to receive mammograms than heterosexual women and, if diagnosed with breast cancer, are less likely to be engaged in treatment (Malone et al., 2019). Lesbians are less likely to receive HPV vaccinations for cancer prevention than heterosexual women, and cisgender sexual minority women and transgender people with a cervix are less likely to receive cervical cancer screening than cisgender heterosexual women (Agénor et al., 2018; Braun et al., 2017; Porsch et al., 2019). Rates of routine cancer screening among intersex populations have not been studied (Gomez-Lobo and Amies Oelschlager, 2016).

These missed opportunities for prevention are often associated with systemic barriers, which include provider misinformation (e.g., the mistaken perception that lesbians do not need Pap smears) and previous patient experiences with and fear of medical maltreatment, which results in reluctance to seek care (Boehmer, 2018). For sexual minority women and transgender men in particular, a lack of access to gender-affirming practices and spaces around breast and cervical cancer screening can be a formidable barrier (Taylor and Bryson, 2015). These spaces are often socially marked as feminine, with pink color schemes, floral gowns, and

women’s magazines in the waiting rooms. Staff and other patients at such sites are often not prepared to see transgender men or masculine-presenting women, and responses to their presence may range from ignorant to hostile (Kamen et al., 2019). Similarly, health plans or providers may make incorrect assumptions about transgender people’s bodies when assessing risk and medical necessity for specific cancer screenings. They also may not be aware that transgender men and non-binary people who retain a cervix require regular Pap tests; transgender women and non-binary people who retain a prostate may require prostate exams, and all people with breast tissue, including transgender men who have had chest reconstruction, may need mammograms (Deutsch, 2016; Pratt-Chapman and Ward, 2020). Barriers to appropriate cancer screenings may be particularly salient for SGD people of color, who may face barriers based on race and ethnicity as well as sexual orientation, gender identity, and intersex status (Malone et al., 2019).

Interventions to Improve Cancer Prevention and Outcomes

Positive, destigmatizing, gender-affirming relationships with health care providers increase acceptance of cervical cancer screening (Agénor et al., 2015; Dhillon et al., 2020) and HPV vaccination (Apaydin et al., 2018) among LGBT people. Sexual minority women and trans-masculine people often prefer self-collected swabs for cervical cancer screening and HPV testing (Goldstein et al., 2020; Johnson et al., 2016; McDowell et al., 2017; Reisner et al., 2018). There is no consensus or national recommendation around screening for anal cancer among gay and bisexual men; however, shared decision making about anal pap smears is recommended for men who have sex with men who are living with HIV (Margolies and Goeren, n.d.; Medical Care Criteria Committee and Brown, 2020).

A brief web-based intervention that provided tailored HPV information and monthly text reminders for gay and bisexual men was associated with increased HPV vaccinations among young sexual minority men (Reiter et al., 2018). Other recommendations for increasing HPV vaccination rates among young sexual minority men include creative use of mobile technology, bundling HPV vaccination with other health services, and increasing vaccine awareness (Fontenot et al., 2016).

The committee found few recent studies of breast cancer interventions for SGD populations. The most recent study described a community-engaged process of developing a culturally tailored breast cancer education program for LGBTQ individuals (Fung et al., 2019). Older studies included a culturally adapted intervention designed to improve breast cancer screening among Black sexual minority women; this intervention trained Black lesbians to be role models and lay health advisors for their community, but no efficacy data from this program have been reported (Washington and

Murray, 2005). Other intervention research included largely white samples: a tailored education intervention increased breast cancer screening in lesbians (Dibble and Roberts, 2003), and a risk counseling intervention with mostly white sexual minority women increased breast cancer screening rates at 24 months (Bowen, Powers, and Greenlee, 2006).

Data suggest that oncology providers could benefit from more education about SGD populations (Lisy et al., 2018; Schabath et al., 2019). A systematic review of LGBTQ anti-bias training for health care providers found that education was effective at increasing knowledge of LGBTQ health issues, experiential learning was effective at increasing comfort levels with LGBTQ patients, and intergroup contact was effective at promoting more tolerant attitudes toward LGBTQ patients (Morris et al., 2019). More research is needed into interventions to improve the full spectrum of cancer prevention, care, and outcomes for SGD populations, including transgender people and people with intersex traits.

SEXUAL AND REPRODUCTIVE HEALTH

HIV and Other Sexually Transmitted Infections

Historically, much of the research on the health of LGBT populations has focused on HIV and other sexually transmitted infections (STIs) (Coulter et al., 2014). This evidence shows that cisgender gay and bisexual men and other men who have sex with men are overrepresented among people living with HIV and represent the largest proportion of new HIV diagnoses every year in the United States (CDC, 2020). Of all the men living with HIV in the United States, 76 percent are gay, bisexual, and other men who have sex with men, and 26,000 men who have sex with men acquire HIV each year (CDC, 2020). Young Black and Latinx men are overrepresented in these numbers (CDC, 2020). Similarly, men who have sex with men are overrepresented among STI incidence and prevalence figures overall (CDC, 2019).

Transgender people, particularly Black and Latina transgender women, are also heavily affected by HIV: a recent meta-analysis found that one in seven transgender women is living with HIV (Becasen et al., 2019). The rates are 44 percent for Black transgender women and 25 percent for Latina transgender women. Data are limited on HIV among transgender men and non-binary people; however, emerging data suggest that transgender men who have sex with men face similar risks for HIV as their cisgender male counterparts (Golub et al., 2019; Reisner et al., 2019). There are fewer and often poorer quality studies of the prevalence of other STIs among transgender people, with estimates that vary substantially by geography, type of STI, and study population (McNulty and Bourne, 2017).

Sexual minority women who inject drugs or have sex with cisgender men face a higher risk for HIV than heterosexual women with the same risk factors (German and Latkin, 2015; Owen et al., 2020). Data on other STIs among sexual minority women are sparse and often low quality; however, they indicate that STI transmission between women does take place (Takemoto et al., 2019). As with many other health conditions, the committee found no published data on HIV or other STIs among intersex people.

Drivers of HIV/STI Disparities

Stigma, violence, and discrimination across multiple axes of identity converge in the lives of LGBT and other SGD people, leading to higher rates of HIV/STI risk behavior and reduced access to and engagement in prevention (e.g., pre-exposure prophylaxis, condoms) and care services (e.g., anti-retroviral therapy) (Earnshaw et al., 2013; McNulty and Bourne, 2017; Mimiaga et al., 2019a; Mustanski et al., 2017; Nuttbrock et al., 2015; Poteat et al., 2016; Reisner et al., 2016b, 2020a; Sevelius et al., 2020a). Reduced access to protective structural assets, such as stable housing, employment opportunities, and affirming health care, are some of the mechanisms linking stigma to HIV/STI disparities for LGBT populations. For example, employment discrimination limits income-generating opportunities for many transgender women (James et al., 2016). As a result, survival sex work is common and, in the context of criminalization, is associated with increased vulnerability to contracting HIV (Becasen et al., 2019). A lack of access to gender-affirming care has also been identified as an HIV risk factor among transgender women (Sevelius et al., 2019).

Interventions to Address HIV and Other STIs

The magnitude of the burden of HIV and other STIs on LGBT populations has generated substantial research into effective interventions to eliminate these disparities. A growing body of data suggests that stigma-reduction interventions may be effective in reducing sexual risk behavior and improving engagement in HIV care (Mimiaga et al., 2018; White Hughto, Reisner, and Pachankis, 2015; Yang et al., 2018). A recent systematic review of multiple stigma reduction interventions to improve HIV prevention and care outcomes among men who have sex with men identified three main approaches: (1) education and mobile health strategies that reduce internalized and anticipated stigma by promoting self-acceptance, leadership, and motivation for behavior change; (2) peer support and training of health care providers to increase social support, knowledge sharing, and empowerment; and (3) community leader sensitization to reduce enacted and anticipated stigma (Dunbar et al., 2020).

There is strong evidence for the efficacy of group- and community-level behavioral interventions to reduce sexual risk behavior among men who have sex with men (Lorimer et al., 2013). Among a review of more than 100 studies, interventions that were based on a theoretical framework, delivered by trained professionals, and focused on skills building were the most consistently effective (Lorimer et al., 2013). HIV/STI prevention research with sexual minority men has increasingly focused on e-health interventions, including web-based, text-based, online-video, computer-assisted, multimedia, social network virtual simulation, and smartphone applications (Nguyen et al., 2019). A recent systematic review (Henny et al., 2018) identified 55 interventions, of which 49 achieved short-term risk-reduction behavior change; however, of the 4 studies with 12-month follow-up, only 1 of them maintained behavior change over this period. In a review of 45 e-health interventions that addressed the HIV care continuum, mobile texting was the technology most commonly reported (44%) (Henny et al., 2018). Medication adherence (60%) was the most common outcome measured, and 20 percent of interventions measured HIV viral suppression. Approximately 75 percent of studies showed preliminary or proven efficacy. Many of them relied on mobile technology and integrated knowledge or cognition as behavior change mechanisms.

HIV pre-exposure prophylaxis (PrEP) has been a particularly powerful innovation in HIV prevention, capable of reducing HIV risk by more than 90 percent for individuals who adhere to prescribed regimens (Fonner et al., 2016). However, PrEP uptake and adherence has been low, particularly among Black and Latinx transgender women and men who have sex with men (Kanny et al., 2019; Poteat et al., 2019). Existing data suggest that addressing intersectional economic, institutional, interpersonal, and psychosocial barriers to PrEP is critical for effective HIV prevention in these populations (Cahill et al., 2017; Poteat et al., 2017). Employment and other structural intervention studies are currently under study to test their efficacy to reduce HIV/STI vulnerability among transgender women (Benotsch and Zimmerman, 2017; HIV Prevention Trials Network, n.d.) and gay and bisexual men (Hill et al., 2020).

Multiple studies with serodiscordant male sexual partners have demonstrated that HIV transmission does not occur when the partner living with HIV is engaged in effective antiretroviral treatment (Yombi and Mertes, 2018). Advocates have led an education campaign using the slogan “U = U”—“undetectable equals untransmittable”—which has been endorsed by multiple organizations, including the Centers for Disease Control and Prevention (Lancet HIV, 2017). Ensuring that SGD people living with HIV have access to affirming health care from providers who are knowledgeable about current best practices in HIV prevention and treatment is critical both to increasing PrEP uptake and to the success of U = U.

The committee identified only one STI intervention designed for cisgender sexual minority women. A group-based, six-session, psychoeducational intervention with cisgender lesbian, bisexual, and queer women significantly increased sexual risk-reduction practices, STI knowledge, and self-efficacy for barrier use six weeks after the intervention ended (Logie et al., 2015). Similarly, the committee found only one intervention tailored specifically for transgender men: LifeSkills for Men, which adapted a small group-based behavioral HIV prevention intervention originally designed for young transgender women to address the unique needs of young transgender men who have sex with men (Reisner et al., 2016c). A pilot test found the intervention to be feasible and acceptable, with trends suggesting reduced HIV/STI risk behaviors across four months of follow-up.

Multiple group-based behavioral HIV prevention interventions developed for transgender women have shown some evidence of efficacy (Poteat et al., 2017). However, most were limited by less rigorous pre-post designs, short follow-up periods, or lack of any outcome evaluation. The only published full-scale behavioral HIV prevention randomized controlled trial for transgender women to date has been Project LifeSkills for young transgender women (Garofalo et al., 2018). This empowerment-based group intervention was delivered in six 2-hour sessions over 3 weeks, and intervention participants reduced condomless sex acts by 40 percent over 12 months of follow-up when compared with participants in a control group. One “status-neutral” peer-led group intervention, Sheroes, has demonstrated high feasibility, acceptability, and preliminary efficacy (Sevelius et al., 2020b). In another study of a couples-based HIV prevention intervention, transgender women and their primary cisgender male partners were randomized to a couples-based HIV prevention intervention comprised of three counseling sessions (two couples-focused sessions, which discussed relationship dynamics, communication, and HIV risk, and one individual-focused session on HIV prevention concerns) or a control condition (one session on general HIV prevention delivered to both partners together). At 3-month followup, participants in the intervention condition had 50 percent reduced odds of condomless sex with primary partners and 30 percent reduction with casual partners relative to the control condition (Operario et al., 2017). As part of a Special Project of National Significance, the Health Resources and Services Administration in the Department of Health and Human Services recently funded nine sites across the country to implement and evaluate interventions to improve care engagement for HIV-positive transgender women of color (Rebchook et al., 2017). While each intervention was different, common elements included community outreach, peer navigation, access to gender-affirming medical care (e.g., hormone therapy), case management, and transgender-competent HIV care (Chapter 12 discusses the lessons learned from this project).

Sexual Function

Most sexual health research with SGD populations, particularly transgender women and gay men, has focused on HIV/STIs, with less attention to other sexual health domains, such as desire, arousal, orgasm, pleasure, and other aspects of sexual function (Stephenson et al., 2017; Wade and Harper, 2017). However, evidence indicates that sexual minority men may report lower orgasm frequency, pleasure, and satisfaction than heterosexual men, and bisexual women report greater physical discomfort during sex and fewer orgasms than lesbians (Flynn, Lin, and Weinfurt, 2017). In an online convenience sample of almost 53,000 adults, heterosexual men were most likely to report that they usually or always orgasmed when sexually intimate (95%), followed by gay men (89%), bisexual men (88%), lesbian women (86%), bisexual women (66%), and heterosexual women (65%) (Frederick et al., 2018).

The study of sexual function among transgender people has focused on genital sensation after gender-affirming surgeries (Frey et al., 2017). Though limited by convenience sampling and small sample sizes, existing studies indicate that most transgender adults retain the ability to achieve orgasm and report satisfaction with their sexual functioning after gender-affirming surgeries (Sigurjonsson et al., 2017; Stephenson et al., 2017). A large European study of transgender adults found increases in sexual desire and arousal after surgery (Kerckhof et al., 2019). Data on sexual function among transgender people who have not had gender-affirming surgeries are limited.

Studies on sexuality among people with intersex traits have focused disproportionately on sexual function as an outcome of childhood genital surgery (see Chapter 12). High rates of sexual dissatisfaction, sexual inhibition, and sexual problems have been found across variables of gender, genital difference, specific intersex condition, or having undergone prior surgery (Kreukels et al., 2019). Studies have consistently linked prior history of clitoral surgery with decreased genital sensation and anorgasmia in comparison with intersex individuals who had not undergone clitoral surgery. With or without surgical intervention, concerns about genital appearance may affect sexual function for some intersex people (Gomez-Lobo and Amies Oelschlager, 2016; Meyer-Bahlburg et al., 2018; van der Horst and de Wall, 2017). Multiple studies have found reports of dissatisfaction with genital appearance and satisfaction with genital function among intersex adults (Kreukels et al., 2019). Overall, concerns about long-term effects on sexual function from surgery performed in infancy support arguments to delay surgical intervention until the patient can provide informed consent. Ethical and other considerations around early genital surgeries for infants with intersex traits are discussed in more detail in Chapter 12.

Published studies assessing influences on sexual function among SGD populations are rare, and large gaps remain in understanding the relationship between minority stress and sexual function (Grabski and Kasparek, 2017; Grabski et al., 2018). Research on sexual function among LGBT and intersex people has been limited by the degree to which existing measures center and normalize cisgender, heterosexual, and non-intersex experiences of anatomy, desire, and sexual behavior, as well as researchers’ failure to develop and use research instruments that have been validated among SGD populations (McDonagh et al., 2014; Reisner et al., 2020b). Better research tools to assess all domains of sexual health for LGBT, intersex, and other SGD people are needed (Barone et al., 2017; Sobecki-Rausch, Brown, and Gaupp, 2017). Given this lack of basic information about sexual function among SGD people, it is not surprising that no SGD-specific or SGD-inclusive interventions to improve sexual function were identified in the published literature.

Fertility and Contraception

Technological advances have greatly increased reproductive options for SGD populations. However, data on the prevalence and success rates of assisted reproduction among these populations are sparse. A systematic review of donor intrauterine insemination, in vitro fertilization, and gestational surrogacy among sexual minorities suggests that same-sex couples have higher success rates with assisted reproduction than their heterosexual counterparts (Tarin, Garcia-Perez, and Cano, 2015). However, studies have been limited by sampling bias, small sample sizes, and failure to control for influential covariates, such as age, smoking, reproductive history, and variation in intervention protocols.

Young sexual minority women, particularly bisexual women, have a higher rate of unintended pregnancy than their heterosexual peers, but there has been little study of their fertility behaviors (Ela and Budnick, 2017). In a recent longitudinal study of pregnancy risk among sexual minority women that examined possible reasons for this higher rate, which followed participants for 30 months, investigators found that sexual minority women had more partners, more sexual intercourse with men, less frequent contraceptive use, less use of a dual method of contraception (condom plus hormonal method), and more gaps in contraception use than heterosexual women. These findings highlight the importance of counseling on contraception and family planning for sexual minority women (Ela and Budnick, 2017).

Gender-affirming medical or surgical therapies for transgender individuals may result in reduced or complete lack of fertility (Cheng et al., 2019). Suppression of puberty with gonadotropin-releasing hormone

analogs can pause the maturation of germ cells and thus affect fertility potential. Testosterone therapy can suppress ovulation and alter ovarian histology, while estrogen therapy can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery that includes oophorectomy or orchiectomy results in permanent sterility; see Chapter 12.

Research indicates that clinicians should counsel transgender patients on fertility preservation options prior to initiation of gender-affirming therapy (Cheng et al., 2019). A narrative review of fertility preservation among gender minorities found that many transgender adults want the option of fertility preservation (Rowlands and Amy, 2018). The current fertility preservation options for transgender people with ovaries and a uterus are embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation. For transgender people with testes, sperm cryopreservation, surgical sperm extraction, and testicular tissue cryopreservation are available. Transgender people face many barriers to fertility care, such as provider discrimination; lack of information; lack of insurance coverage; legal barriers, such as heterosexist and gendered requirements in state fertility coverage mandates; scarcity of fertility centers; financial burden; and emotional cost (Cheng et al., 2019). These barriers mean that all transgender people need to be informed of available fertility preservation options (De Roo et al., 2016; Knudson and De Sutter, 2017).

Data suggest that transgender men have limited access to reproductive health services and information, even if they are able to become pregnant (Cipres et al., 2017). One study of almost 200 transgender men found that many used contraception and had experienced pregnancy and abortion, even after social and hormonal gender affirmation (Light et al., 2018). Some contraceptive options may be undesirable to transgender men due to exposure to gender-incongruent hormones, like progestins or estrogens, or the requirement of pelvic exams for placement of intrauterine devices. Transgender men need gender-affirming counseling and care regarding reproductive health, and systems- and provider-level interventions are needed to create gender-affirming and inclusive reproductive health care environments and services (Hahn et al., 2019). Discrimination and other barriers to clinically appropriate and culturally responsive health care for transgender people are discussed in detail in Chapter 12.

Infertility is a common feature of some, but not all, intersex conditions (El-Maouche et al., 2017; Mooij et al., 2017). At the same time, intersex adolescents and adults who have a uterus and no or infrequent menstrual bleeding may erroneously assume that they do not need contraception and may thus be at risk for an unintended pregnancy. Unplanned pregnancies among people with intersex traits may be associated with higher rates of

spontaneous abortions, fetal malformation, and chromosomal abnormalities than among people without intersex traits. Very few data exist on the efficacy of cryopreservation in intersex individuals with viable gametes (Schleedoorn et al., 2019). Even when there has been evidence of efficacy, follow-up data are lacking. Discussion of parenting desires and options, including through adoption, donor gametes, and gestational surrogacy, is an important part of informed consent for hormonal and surgical interventions for individuals with intersex traits (Van Batavia and Kolon, 2016). Access to reproductive health specialists who are knowledgeable about intersex traits and who can discuss options for contraception, fertility preservation, and pregnancy is essential (Gomez-Lobo and Amies Oelschlager, 2016), as is further research on fertility options for intersex individuals.

VIOLENCE AND VICTIMIZATION

Numerous studies show that LGBTQ people experience high rates of violence and victimization that begin early in the life course and persist into adulthood. Specific types of violence documented against LGBTQ people include family violence (McGeough and Sterzing, 2018); intimate partner violence (Edwards, Sylaska, and Neal, 2015; Finneran and Stephenson, 2013; Peitzmeier et al., 2020); sexual violence (Chen et al., 2020; Langenderfer-Magruder et al., 2016); police violence (DeVylder et al., 2017, 2018); and structural violence, such as exclusion and discrimination in health care, employment, education, public accommodations, and other areas of everyday life (Casey et al., 2019). Hate crimes, including physical assault and other forms of bias-motivated violence, are also a serious concern for SGD people (Boynton et al., 2020; Burks et al., 2018; Coston, 2018; Cramer et al., 2018; Herek, 2008; Herek, Gillis, and Cogan, 1999; Katz-Wise and Hyde, 2012; Mills, 2019). Violence and victimization affecting people with intersex traits is an understudied issue, though interviews with families reveal that potential bullying on the basis of intersex traits is often cited by clinicians as a reason to have genital surgery in childhood (Human Rights Watch, 2017).

Evidence indicates that LGBTQ youth disproportionately encounter violence and victimization relative to heterosexual and cisgender youth (Edwards, 2018; Johns et al., 2018, 2019b; Olsen et al., 2017; Poteat et al., 2020; Rostad et al., 2019). These experiences include being bullied electronically or at school, being threatened or injured with a weapon at school, experiencing sexual or physical dating violence, and feeling unsafe at or traveling to or from school. Elevated rates of adverse childhood experiences, including physical and sexual abuse, have also been found in LGBTQ populations (Baams, 2018; Merrick et al., 2018). LGBTQ adolescents have increased rates of polyvictimization—experiencing multiple

forms of victimization—relative to their non-LGBTQ peers (Baams, 2018; Schwab-Reese et al., 2018).

SGD people may also experience unique forms of victimization, such as identity abuse (Woulfe and Goodman, 2018), in which perpetrators leverage systems of structural oppression to harm individuals. For instance, perpetrators may use aspects of transphobia, such as withholding gender affirmation or using the threat of “outing,” as a form of blackmail to assert power and control over a transgender person (Peitzmeier et al., 2019). So-called “gay panic” or “transgender panic” defenses, in which defendants, typically cisgender men, leverage societal homophobia or transphobia to escape punishment in criminal cases involving the assault or murder of a gay, lesbian, bisexual, or transgender person, are also related to identity abuse (Woods, Sears, and Mallory, 2016). Few studies have characterized perpetrators of violence and victimization against LGBT people (Coston, 2018).

Drivers of Violence and Victimization

The elevated rates of violence and victimization experienced by SGD people are rooted in societal oppression, stigma, and bias against LGBT and other SGD people. There are different patterns of violence and victimization on the basis of gender (i.e., identity as male, female, or non-binary) and transgender status. For example, youth who are both LGBQ and transgender have been shown to be at highest risk of past-year intimate partner violence, indicating that stigmatized sexual orientation and gender identity interact to structure risk of exposure to violence (Walls et al., 2019). Similarly, childhood gender nonconformity (i.e., having a gender expression that differs from societal expectations for feminine or masculine appearance and behavior) is associated with greater violence and victimization, independent of sexual orientation or gender identity (Adhia et al., 2018; Baams, 2018; Gordon et al., 2018; Klemmer et al., 2019; Roberts et al., 2012a, 2013).

Violence and victimization that target people because of their sexual orientation, gender identity, or intersex status are often exacerbated by racism, sexism, and xenophobia. For instance, high homicide rates for Black transgender women reveal increased vulnerability to gender-based violence at the intersection of race and gender identity (Dinno, 2017; Wirtz et al., 2020).

Interventions to Address Violence and Victimization

A systematic review of peer-reviewed literature from 2000 to 2019 on interventions and their effectiveness in preventing or reducing violence and victimization for LGBT youth identified only one intervention, anti-bullying laws (Coulter et al., 2019). These laws have been shown to help reduce

bullying victimization, particularly for sexual minority boys (Seelman and Walker, 2018). Protective laws that specifically include sexual orientation reduce the risk of suicide attempts, forced sexual intercourse, and feeling unsafe at school or on the way to or from school among all youth, regardless of sexual orientation (Meyer et al., 2019). In a meta-analysis of 15 primary studies with 62,923 participants, gay-straight alliances were associated with significantly lower levels of self-reported homophobic victimization, safety fears, and hearing homophobic remarks (Marx and Kettrey, 2016; see also Chapter 9). A recent cluster randomized control trial that tested the efficacy of a bystander intervention to reduce violence and violence acceptance for sexual minority male and female high school students in Kentucky was effective at reducing violence for heterosexual students but was less effective for sexual minority youth, particularly sexual minority males (Coker et al., 2020). This outcome points to the need for ongoing research to develop, design, and test interventions to address violence and victimization against LGBTQ youth.

In addition to anti-bullying laws, other structural interventions at the state and federal levels have sought to address violence and victimization against LGBTQ people. As of 2020, 11 states have banned gay and transgender panic defenses (Movement Advancement Project, 2020). Legal equality in the form of state policies for same-sex partnerships, employment nondiscrimination, and hate crimes laws has been shown to decrease the incidence of hate crimes based on sexual orientation (Levy and Levy, 2017). Sexual orientation and gender identity are included in the federal hate crimes law, which provides for enhanced criminal penalties in cases of bias-motivated violence and also requires improved tracking of hate crimes perpetrated against LGBTQ people (Mattson, 2018). Hate crimes laws are controversial, however, because of their potential to be misused against defendants from poor communities or communities of color, which are already over-policed and disproportionately represented in the criminal justice system (Swiffen, 2018).

Trauma-informed interventions are critical to address violence and victimization among LGBTQ people, but these interventions remain underdeveloped (Niolon et al., 2017; Peitzmeier et al., 2020). A recent scoping review found no SGD-specific programs to prevent or address intimate partner violence in SGD people (Subirana-Malaret, Gahagan, and Parker, 2019). However, interventions to mitigate the health-related sequelae of violence for SGD people are being developed and tested. For example, an intervention for HIV-negative men who have sex with men who have history of childhood sexual abuse was developed to address HIV acquisition risk and posttraumatic stress by integrating HIV risk reduction with modified cognitive and behavioral therapy for posttraumatic stress, trauma, and self-care (CBT-TSC). A randomized study of men who have sex with men found that

those who were assigned to CBT-TSC had reduced odds of condomless sex with an HIV-positive or unknown status partner; they also had reduced odds of posttraumatic stress disorder (PTSD) and avoidance symptoms relative to those in the control condition assigned only to HIV voluntary counseling and testing (O’Cleirigh et al., 2019). Additional interventional research is needed to prevent and address violence in SGD populations.

MENTAL AND BEHAVIORAL HEALTH

Mental Health

Much of the early literature on the health of LGBT populations centered on mental health disparities and existed in tension with the misuse of mental health diagnoses to justify discrimination against and social exclusion of LGBT people. Since the release of the Institute of Medicine (2011) report, there has been a surge in research empirically evaluating determinants of and interventions for improving the mental health of LGBT and other SGD populations. Research indicates that disparities in SGD population mental health compared with the non-SGD population appear as early as adolescence and may persist even into older adulthood (Fredriksen-Goldsen et al., 2015).

Adolescence is a vulnerable time for the development of mental health symptoms. Studies have consistently found that higher rates of mood and anxiety disorders, PTSD, eating disorders, and substance use disorders emerge in adolescence for LGBT populations (Plöderi and Tremblay, 2015; Russell and Fish, 2016). Suicide is the second leading cause of death for youth aged 10 to 24 (Heron, 2019), and a recent systematic review and meta-analysis of population-based longitudinal studies found a significantly higher risk of suicide attempts for LGB youth relative to same-age heterosexual controls (Haas et al., 2011; Miranda-Mendizábal et al., 2017).

Mental health disparities that begin in adolescence can persist far into adulthood (Fredriksen-Goldsen et al., 2013). LGBT adults are at higher risk than non-LGBT adults for mental health problems, such as depression, anxiety, anorexia nervosa, and bulimia nervosa (Hottes et al., 2016; McClain and Peebles, 2016; Plöderi and Tremblay, 2015). On a spectrum of suicidality anchored at one end by suicide attempts, research has produced evidence identifying increased risk in LGBT populations of other suicidal symptoms, such as non-suicidal self-injury and suicidal ideation (Jackman, Honig, and Bockting, 2016; Liu and Mustanski, 2012). There is also some evidence that severe mental illness—defined by the requirement of extensive psychiatric treatment in inpatient and outpatient settings and resulting in significant disability in one or more major life domains (Parabiaghi et al., 2006)—may occur at higher rates among LGBT populations.

Mental health risks vary among SGD groups. For instance, there is some evidence of higher rates of depression, eating disorders, and suicidality among bisexual people relative to lesbian and gay people (Plöderi and Tremblay, 2015; Pompili et al., 2014). In comparison with cisgender adults, transgender adults report elevated rates of psychiatric diagnoses, such as major depressive disorder, anxiety disorders, PTSD, and eating disorders (Connolly et al., 2016; Dhejne et al., 2016; Fredriksen-Goldsen et al., 2014; James et al., 2016; Marshall et al., 2016; Mueller, De Cuypere, and T’Sjoen, 2017). Among military veterans, there is evidence of higher rates of suicidality for both LGB and transgender people and higher rates of depression, PTSD, serious mental illness, and sexual trauma among transgender people (Blosnich, Bossarte, and Silenzio, 2012; Brown and Jones, 2015).

Less is known about the epidemiology of mental health problems among intersex populations in the United States, as no population surveys currently assess intersex status (Tamar-Mattis et al., 2018). Research is often limited to a primary variable of surgical or medical treatment with identified outcomes of gender dysphoria and general health-related quality of life (Sandberg, Gardner, and Cohen-Kettenis, 2012). When particular psychiatric and neurocognitive outcomes are evaluated, it is generally in the context of a specific intersex condition (differences of sex development [DSD]). For instance, congenital adrenal hyperplasia and Kleinfelter and Turner syndromes have been associated with attention deficit hyperactivity disorder and autism (de Vries et al., 2019).

There has been much more research into the mental health and well-being of parents of infants and children with intersex traits than for people with intersex traits themselves, and much of this research has been in the context of making decisions regarding early genital surgery (Wisniewski, 2017). The dsd-LIFE Group, a multicenter European study that looked at mental health and quality of life among people with intersex traits, is a notable exception that has no current correlate in the United States (de Vries et al., 2019). Among the 1,022 participants in the dsd-LIFE study, all males and some females with specific DSDs reported increased rates of depression and anxiety relative to country-specific reference populations.

Research regarding the mental health of SGD populations of color has yielded mixed findings. For instance, among respondents to the American College Health Association National College Health Assessment-II surveys from 2008 and 2009, there were lower rates of depression for Asian, Black, and Latinx LGB students than for white LGB students (Lytle, De Luca, and Blosnich, 2014). In contrast, relative to white students, Black and multiracial students reported significantly higher rates of suicide attempts, while Latinx students reported lower rates of suicidal ideation and attempts, though this difference was not statistically significant. The 2015 U.S. Transgender Survey (USTS) found that Black, Native American, Asian,

Latinx, Middle Eastern, and multiracial transgender adults reported higher rates of past-year and lifetime suicide attempt than white respondents, with the highest rates for Native American and multiracial respondents (James et al., 2016). An analysis of the Aging with Pride: National Health, Aging, and Sexuality/Gender Study population found decreased mental health-related quality of life for the older LGBT participants who were Black and Hispanic relative to white participants (Kim, Jen, and Fredriksen-Goldsen, 2017).

Drivers of Mental Health Disparities

Mental health disparities among LGBT and other SGD populations are consistent with stress responses to external factors, such as stigma, discrimination, and violence (Clements-Nolle et al., 2018; James et al., 2016; Nuttbrock et al., 2014; Perez-Brumer et al., 2017; Reisner et al., 2016d; Whitton et al., 2016). Bias-motivated violence, such as hate crimes based on sexual orientation or gender identity, may have particularly severe psychological consequences for LGBT people (Herek, Gillis, and Cogan, 1999). Internalized stigma and attempts to conceal one’s identity to avoid stigma have been associated with psychiatric symptoms and psychological distress among LGBT populations and with suicide attempts among transgender adults (Gevonden et al., 2014; Hatzenbuehler and Pachankis, 2016). Conversion therapy that attempts to change sexual orientation or gender identity is also a mental health stressor for LGBT people: LGBT populations are at risk for exposure to conversion therapy, and exposure to conversion therapy is a risk factor for mental health problems. This topic is discussed in detail in Chapter 12.

Among LGBTQ youth, victimization on the basis of sexual orientation or gender identity is associated with worse depression, more anxiety, lower self-esteem, less school belonging, and higher prevalence of suicidality than for non-LGBTQ youth (Kosciw et al., 2018). Negative mental health symptoms, suicidal ideation and attempts, and risky behaviors among youth have been correlated with living in areas with higher rates of assault-based hate crimes against LGBT people or higher scores on composite indices of structural stigma (Hatzenbuehler and Pachankis, 2016). For example, in a population-based sample of 9th- through 12th-graders in Boston public schools, sexual minority youth residing in neighborhoods with higher rates of LGBT assault hate crimes were significantly more likely to report suicidal ideation and suicide attempts than those living in neighborhoods with lower rates of LGBT assault hate crimes (Duncan and Hatzenbuehler, 2014). No similar associations were found between LGBT assault hate crimes and either suicide ideation or attempt in heterosexual students, indicating that the results were specific to sexual minority adolescents. Furthermore, there

were no significant associations for non-LGBT crimes and suicidality in sexual minority adolescents, indicating the specificity of results to LGBT assault hate crimes.

Retrospective reports of adverse childhood experiences are also correlated with negative mental health outcomes and psychiatric illness in LGBT populations (Blosnich and Andersen, 2015; Hughes et al., 2017). A systematic review and meta-analysis of 73 studies that included more than 47,000 LGBT adults found high rates of such events, including interpersonal stigma and victimization, among LGBT participants (Schneeberger et al., 2014). Thus, exposure to higher numbers of adverse childhood experiences may contribute to the elevated rates of negative mental health outcomes found among LGBT people (McLaughlin et al., 2012; Roberts et al., 2012b).

Among SGD populations, some associations between mental health outcomes and exposure to stressors, stigma, and victimization are unique to specific groups. Bisexual women, for example, have a higher lifetime prevalence of rape and sexual assault than lesbian or heterosexual women, which may correlate with poorer mental health outcomes (Schulman and Erickson-Schroth, 2019). LGBT individuals with serious mental illness experience intersecting heterosexism and cisgenderism in psychiatric settings and ableism in LGBT spaces, which may exacerbate disparities (Kidd et al., 2016; Wong et al., 2014).

Though there are no studies of minority stress specifically among intersex populations, the dsd-LIFE study in Europe found that mediating factors for mental health disparities affecting people with intersex traits included self-esteem, openness, and shame (de Vries et al., 2019), which are consistent with experiences of minority stress. Similarly, experiences of social, sexual, and medical stigma have been found to occur among individuals with intersex traits (Ediati et al., 2017; Meyer-Bahlburg et al., 2017a, 2017b, 2018). There are as yet no studies specifically exploring the ways in which structural or interpersonal stigma or minority stressors might influence intersex health disparities.

Military service may confer both risks and benefits to mental health. There is some evidence that LGBT people may be at higher risk of victimization than non-LGBT people while serving (Goldbach and Castro, 2016), though data are limited. Of the 3 percent of 2015 USTS respondents who were on active duty military, nearly 50 percent reported support from their commanding officers in social transition, though only 36 percent reported support in medical transition (James et al., 2016). However, there may also be a benefit to feeling a sense of belonging in a military or veteran population (Matarazzo et al., 2014). Respondents in the 2015 USTS reported nearly twice the rate of prior military service as the general population (15% and 8%, respectively), and despite higher rates of unemployment, serious psychological distress, and suicide attempts relative to the general

population, all rates were lower than those reported by nonveteran respondents (James et al., 2016). These findings are consistent with data from a 2014 survey of 183 transgender older adults, for whom prior military service predicted fewer depressive symptoms and greater health-related quality of life (Hoy-Ellis et al., 2017).

SGD populations of color may also experience minority stressors and stigma on the basis of their racial or ethnic identity, which may contribute to some findings of elevated mental health risk. Among older LGBT people of color, mediators of mental health quality of life included markers of stigma and stress, such as income, education, identity affirmation, social support, and discrimination (Kim, Jen, and Fredriksen-Goldsen, 2017). Similarly, disparate rates of mental health problems among respondents of color to the USTS were mediated by victimization events (James et al., 2016).

Interventions to Address Mental Health Disparities

Emerging evidence has revealed interventions that improve mental health outcomes among SGD populations. Among adults, psychotherapies specifically created for LGBT individuals have been associated with improved mental health (Diamond et al., 2012; Hatzenbuehler and Pachankis, 2016; Lucassen et al., 2015). Additional interventional research is under way, including a transdiagnostic treatment approach to specifically address the cognitive, affective, and behavioral effects of minority stress processes for young adult sexual minority men (Pachankis et al., 2019). There are few data to guide interventions for LGBT people with serious mental illness (Evans et al., 2016). Training emphasizing cultural competency in relation to sexual orientation, gender identity, and intersex status for mental health providers and mental illness training for LGBT- and intersex-oriented service providers may be useful in improving care and outcomes, especially if such training results in LGBTI individuals feeling safe in disclosing more aspects of their identity to their providers (Kidd et al., 2016). Robust work has found that supportive home environments, affirming school climates, and laws and policies advancing marriage equality and prohibiting discrimination and bullying correlate with lower rates of suicide ideation and attempts in large, population-based analyses of LGBT youth (Hatzenbuehler and Pachankis, 2016; Raifman et al., 2017).

For transgender individuals, gender-affirming medical treatment and interventions targeted at building self-esteem and resilience through clinical care, support groups, activism, and family support have consistently been associated with improvements in mental health outcomes (Costa et al., 2015; de Vries et al., 2011, 2014; Hughto, Reisner, and Pachankis, 2015).

Family support was strongly associated with lower rates of psychological distress and lifetime suicide attempt in 2015 USTS respondents (James et al., 2016). Peer support has also been associated with improved psychosocial well-being for adults with intersex traits and has been recommended as a routine and essential part of intersex care (Krege et al., 2019; Lee et al., 2016). Unfortunately, there appears to be a relative absence of research on interventions targeted specifically at improving mental health among LGBT older adults, bisexual people, LGBT military personnel and veterans, LGBT people of color, and intersex adults.

Substance Use and Behavioral Health

SGD populations are disproportionately burdened by substance use disorders across the life course, including use of tobacco, alcohol, and other drugs (Azagba, Latham, and Shan, 2019; Azagba et al., 2020; Boyd et al., 2019; Dai and Meyer, 2019; Gattamorta, Salerno, and Castro, 2019; Gonzales and Henning-Smith, 2017; Gonzales, Przedworski, and Henning-Smith, 2016; Hoffman et al., 2018; Kerridge et al., 2017; Krueger, Fish, and Upchurch, 2020; McCabe et al., 2019a, 2019b; Schuler et al., 2018). Substance use rates are consistently high for sexual minorities regardless of whether sexual orientation is measured as sexual identity, sexual attraction, or sexual behavior (Kerridge et al., 2017). There is substantial heterogeneity by gender identity and expression in substance use behaviors among the transgender population (Azagba et al., 2019; Buchting et al., 2017; Hoffman et al., 2018; Lowry et al., 2018; Newcomb et al., 2019; Watson et al., 2020). There is as yet no research on substance use among intersex populations.

Substance use disparities begin early for LGBT populations, with evidence showing that LGBT adolescents are at greater risk of substance use and misuse when compared with their heterosexual and cisgender peers (Day et al., 2017; Johns et al., 2018, 2019b; Johnson et al., 2019; Lowry et al., 2017; McCabe et al., 2013; Mereish, 2019; Phillips et al., 2019; Schuler and Collins, 2019). These substance use disparities may continue into young adulthood (Coulter et al., 2015; Jun et al., 2019) and persist well into older adulthood (Dai and Meyer, 2019).

It is important to consider subgroup differences when assessing substance use among SGD populations. For instance, prevalence and patterns of substance use behaviors, substance use disorders, and substance use morbidities are particularly heightened for bisexual people (Boyd et al., 2019; McCabe et al., 2019a, 2019b) and sexual minority women (Cochran, Björkenstam, and Mays, 2017; Fish, Hughes, and Russell, 2018; Kerridge et al., 2017; Krueger, Fish, and Upchurch, 2020; McCabe et al., 2019a, 2019b; Schuler et al., 2018).

Drivers of Substance Use and Behavioral Health Disparities

Substance use morbidity for LGBT people may result from exposure to high levels of minority stress from their disadvantaged social status; homophobic, biphobic, or transphobic bullying; or maladaptive coping to stressful life events. For example, in the 2013–2014 California Healthy Kids Survey of 316,766 students in 1,500 middle and high schools (grades 7, 9, and 11), gender- and sexuality-based harassment at school was higher for LGB youth relative to heterosexual youth, was independently associated with greater odds of substance use in every grade, and explained many disparities in substance use between LGB and heterosexual youth (Coulter et al., 2018).

In a nationally representative study using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)III, sexual minorities were at substantially higher risk of severe alcohol use disorder than their heterosexual counterparts, and higher levels of sexual orientation discrimination increased the odds of alcohol use disorder in sexual minorities (McCabe et al., 2019b). This finding suggests that substance abuse prevention and treatment strategies should address sexual minority-specific vulnerabilities. Another study using NESARC-III data found that sexual orientation discrimination and stressful life events each accounted for substance use disorder disparities between sexual minority subgroups and heterosexual adults (Krueger, Fish, and Upchurch, 2020). These findings also suggest that pathways to substance use disorder disparities may differ for different sexual minority subgroups. The age at which exposure to social stressors occurs is also relevant for risk of substance use disorders. A nationally representative sample of non-heterosexual adults found that discrimination based on sexual orientation was most prevalent in early young adulthood, but it increased the odds of substance use disorders only if people were exposed to discrimination at older ages (Evans-Polce et al., 2020).

Due to the lack of gender identity data in U.S. health surveillance systems, population data are limited on pathways to social stress-related substance use disparities for transgender people compared to cisgender people. In nonprobability samples of transgender people, however, social stressors such as discrimination, family rejection, a lack of gender affirmation, and bullying and violence victimization are associated with substance use (Day et al., 2017; Gamarel et al., 2016, 2020; Gilbert et al., 2018; Jannat-Khah et al., 2018; Kidd et al., 2019; Klein and Golub, 2016; Menino et al., 2018; Reisner et al., 2015).

Social norms, social networks, and social support have also been implicated in sexual orientation disparities in substance use. With regard

to social norms, in a probability study of 3,012 middle and high school students (aged 11 to 18) in a mid-sized school district in the southern United States, sexual minority adolescents had higher perceptions of others’ substance use behavior and more permissive perceptions of whether a substance use behavior is approved by others than heterosexual adolescents. These perceptions partially explained disparities for sexual minority youth in both lifetime and current substance use risk (Mereish et al., 2017). The National Longitudinal Study of Adolescent to Adult Health (Add Health) study found that social network factors, including higher frequency or quantity of tobacco use and drinking to intoxication, reflected sexual orientation disparities in alcohol misuse (Hatzenbuehler, McLaughlin, and Xuan, 2015). An analysis of NESARC-III data found that functional support was associated with lower rates of alcohol use disorder for some sexual minorities, while structural support (type and frequency of kin and non-kin contact) increased the risk for other groups (Kahle et al., 2019).

Interventions to Address Substance Use and Behavioral Health Disparities

A review of LGBT substance use research between 2013 and 2017 found an emphasis on individual-level risk factors and a need for additional studies of protective factors and group differences by race and ethnicity, sex assigned at birth, sexual orientation, and gender identity (Kidd et al., 2018). Also needed are nationally representative samples and translation of findings into interventions to prevent and treat substance use for LGBT people. Research on substance abuse treatment utilization is underdeveloped and relies heavily on nonprobability samples (Flentje et al., 2015; Glynn and van den Berg, 2017). In a nationally representative study of adults, among those with any lifetime substance use disorder, some sexual minority adult groups had higher odds of lifetime substance abuse treatment utilization than others (McCabe et al., 2013). Nonetheless, many SGD persons who need substance use treatment do not access it due to stigma and other barriers to care (Allen and Mowbray, 2016) (see Chapter 12). Protective factors for reducing substance use among transgender and gender diverse youth are parent connectedness and higher levels of teacher connectedness (Gower et al., 2018).

There is a dearth of programs and treatments to prevent or intervene on substance use disparities in LGBT populations. In a systematic review of the peer-reviewed literature from 2000 to 2019 on interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization in LGBT youth, only 12 interventions were identified, of which 2 were for substance use (Coulter et al.,

2019). Another review identified large research gaps in the area of tobacco prevention and cessation interventions for SGD youth and young adults (Baskerville et al., 2017). Some interventional research has addressed substance use in the context of sexual risk for HIV acquisition or transmission in gay and bisexual men (Mimiaga et al., 2019b; Parsons et al., 2014). For example, a randomized controlled trial of a tailored, culturally sensitive intervention for homeless gay and bisexual men found significant reductions in stimulant use over time for men assigned to a nurse case management plus contingency management or to a standard education plus contingency management program (Nyamathi et al., 2017). More rigorous research is needed, including studies to determine if adaptations of evidence-based interventions that include minority stress and other SGD-specific concerns are more effective than treatment as usual (Bochicchio et al., 2020). Additional interventional research is needed to understand and mitigate the substance use inequities found in LGBT populations. Research is also needed into the epidemiology, etiology, and treatment of substance use disorders among people with intersex traits.

SUMMARY AND CONCLUSIONS

The physical and mental health of SGD populations, such as lesbian, gay, bisexual, transgender, queer, and intersex people, is substantially affected by external influences that include discrimination, stigma, prejudice, and other social, political, and economic determinants of health. Thus, SGD populations experience both physical and mental health inequities.

In addition to health disparities related to sexual orientation, gender identity, and intersex status, many SGD people also experience health disparities related to intersecting aspects of identity that include but are not limited to race and ethnicity. The associations between stress, stigma, social determinants of health, and health outcomes hold across multiple health conditions. Different social and individual risks may intersect to compound adverse health effects. Cross-cutting resiliency factors appear to mitigate some of these risks and can form the basis for interventions.

In comparison with heterosexual and cisgender populations, SGD populations have less favorable overall health and higher rates of cardiovascular disease, certain cancers, exposure to violence, and HIV and other STIs. Among sexual minority women, lesbian and bisexual women have higher

odds of risk factors for cardiovascular disease, such as hypertension and diabetes, as well as more risk factors for breast cancer. Transgender adults may have elevated rates of cardiovascular disease and myocardial infarction compared with their cisgender counterparts.

LGBT people and people with intersex traits are at risk of violence from family members, peers, intimate partners, and strangers as a result of their sexual orientation, gender identity, or intersex status. Some of the highest risks of violence affect bisexual women and transgender people, particularly transgender women of color. Black transgender women are also disproportionately affected by HIV, as are cisgender gay and bisexual men and other men who have sex with men, who are overrepresented among people living with HIV and represent the largest proportion of new HIV diagnoses every year in the United States.

Mental health disparities in SGD populations include heightened anxiety and depressive symptoms and greater suicidality among LGBT people as compared to heterosexual or cisgender individuals. Substance use and behavioral health disparities include greater use of tobacco, alcohol, and other drugs among LGBT people than among heterosexual or cisgender individuals. Sexual minority individuals are also less likely than their heterosexual counterparts to report healthy sleep, and similar disparities may exist for transgender people.

Because both clinical and population research studies rarely include measures of sexual orientation, gender identity, and intersex status, the full scope and magnitude of physical and mental health disparities and their differential effects across and within SGD populations is not known. There is a particular lack of longitudinal research, representative population surveys, experimental trials, and quasi-experimental studies that collect, analyze, and report health-related data in the context of sexual orientation, gender identity, and intersex status.

Examples of health conditions and risks that are understudied in SGD populations include chronic diseases, such as dementia, cardiovascular disease, and cancer; health behaviors, such as diet, exercise, and sleep; suicidality; all-cause and specific mortality; quality of life; the physical, emotional, and sexual health and well-being of people with intersex traits across conditions and across the lifespan, especially among adolescents and adults who did not have genital surgery; and the physical and mental health of transgender people, including non-binary people. In many of these

areas, reliable instruments and scales validated for use with SGD populations have not yet been developed. There is also a relative dearth of data on intersections with other aspects of identity such as race, ethnicity, age, and disability. Groups for which research is especially lacking include Black, Indigenous, and other people of color; people with intersex traits; asexual, bisexual, and non-monosexual people; and non-binary people.

There is no innate disorder associated with being an SGD individual. Rather, the disparities affecting SGD populations are driven by experiences of minority stress, which include both structural and interpersonal stigma, prejudice, discrimination, violence, and trauma. Minority stress exposures have many mental and physical consequences. Another important concept in relation to minority stress is resilience, which is the ability to maintain normal physical and psychological functioning when stress and trauma occur. More research is needed to elucidate the origins, pathways, and health consequences of minority stress and the factors that support resilience among SGD populations.

The consequences of minority stress are particularly severe for SGD Black, Indigenous, and other people of color, who are affected by exposure to compounded levels of racism, race-related stress, and trauma from multiple sources. They may therefore face stressors that adversely affect their health in ways that differ from and may exceed the disparities facing white SGD populations or heterosexual and cisgender populations of color. A specific focus on intersecting experiences of minority stress associated with both anti-LGBT bias and other forces of structural oppression is lacking in the minority stress literature.

Interventional research in SGD health remains in its infancy. Evidence-based interventions are needed to prevent and address health inequities. These interventions need to address the root causes and multilevel fac-

tors driving SGD health disparities. These factors include vulnerabilities uniquely experienced by SGD people, such as stigma, discrimination, and other sexual and gender minority stressors, as well as intersectional stressors experienced by SGD people living at the intersection of multiple marginalized populations (e.g., racism experienced by Black SGD people). Interventions that address individual, interpersonal, and structural determinants of health are necessary to close SGD health disparities. Developing interventions tailored for specific SGD subgroups, including those targeting risks and harmful exposures specific to those groups (e.g., biphobia, transphobia, racism), and testing whether these tailored interventions are more effective than treatment as usual can help improve SGD population health.

Methodologically rigorous approaches are needed to move interventional research forward for SGD populations. This needed work includes implementing randomized controlled trials for intervention efficacy testing, as well as less traditional methods, such as pragmatic trials, natural experiments, and community-level randomization. In addition, rigorous scientific evaluation of existing and new programs, clinical care and service delivery, and policy and legal changes can help inform future opportunities to improve SGD population health. Leveraging resilience, including building upon strategies SGD people have used to resist societal oppression, is an important part of optimizing SGD health and well-being.

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