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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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1

Introduction

BACKGROUND

More than 11 million lesbian, gay, bisexual, and transgender (LGBT) individuals live in the United States according to 2019 estimates. The past decade has brought remarkable changes in the social, political, and legal status of these individuals. A majority of Americans approve of same-sex relationships and support legal protections to ensure fundamental civil liberties on the basis of sexual orientation and gender identity, representing a dramatic shift from prior years (Gallup, 2018; Pew Research Center, 2017).1

In addition to shifts in public opinion, the laws have changed. The 2015 ruling of the U.S. Supreme Court in Obergefell v. Hodges (576 U.S. 644) extended marriage equality for same-sex couples nationwide. In 2020, the Supreme Court ruled that the prohibition of sex discrimination in Title VII of the Civil Rights Act protects individuals from discrimination based on sexual orientation or gender identity in employment (Bostock v. Clayton County, 140 S. Ct. 171). The logic of the ruling would apply to other federal anti-discrimination laws as well, in such fields as housing, education, and credit. Similarly, many states and municipalities, as well as numerous private corporations, have expanded nondiscrimination protections in workplaces, health care settings, and schools to

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1 Information retrieved from data analyses of the General Social Survey by Gary Gates in 2018, using the Survey Documentation and Analysis online tool maintained by the Institute for Scientific Analysis, San Francisco, CA, under a licensing agreement with the University of California. Tool is available at https://sda.berkeley.edu/sdaweb/analysis/?dataset=gss18.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

include sexual orientation and gender identity. With regard to intersex individuals, a federal court of appeals decision in 2020 ordered the State Department to reconsider its refusal to provide a non-binary gender code for the passport of an intersex individual (Zzyym v. Pompeo, No. 18-1453, 10th Cir. 2020).

Despite increased visibility and social acceptance of sexual and gender diverse (SGD) populations, discriminatory policies and practices remain. Many people who are members of SGD populations—particularly those who are also members of other marginalized populations, such as racial and ethnic minorities—continue to experience stigma, discrimination, and violence where they live, work, play, and pray. In fact, recent evidence among lesbian, gay, and bisexual youth shows more reports of discriminatory experiences in adolescence than for earlier cohorts (Toomey and Russell, 2013), as well as disparities that are growing rather than narrowing for several key health indicators (Fish et al., 2017).

In 2016, the National Institutes of Health (NIH) formally designated sexual and gender minorities as a health disparity population. Researchers have recently begun to explore the relationship between the health disparities affecting the lesbian, gay, and bisexual (LGB) population and specific state- and local-level policy changes using a range of methods, including observational studies, quasi-experimental study designs, field experiments, and laboratory studies (Hatzenbuehler, 2016).

While research on LGBT populations has burgeoned in recent years, much remains to be learned about the status and well-being of these individuals and the ways in which their experiences may differ from those of the general population across many areas, such as physical and mental health, education, relationships, the workforce, and civic participation. Though an increasing number of nationwide surveys include questions about sexual orientation, gender identity, and same-sex partnerships, the extent to which empirical data accurately reflect the communities in question hinges on individuals’ willingness to participate in and disclose their sexual orientation or gender identity on such surveys.

In a major report that described the status of health research on LGBT populations, the Institute of Medicine (2011) identified several challenges to describing and studying the population in question. These challenges included the multifaceted nature of sexual orientation and gender identity, the complexities of defining and operationalizing those constructs, and the resources required for obtaining probability samples of small populations whose members might be reluctant to answer questions about their sexual orientation or gender identity due to concerns about discrimination and victimization. In addition to the lack of standardized, inclusive methods to capture and measure this diverse population, the definitions and analysis of demographic processes, such as fertility and family formation,

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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are predicated on presumed relationships between cisgender, heterosexual individuals. Finally, identifying intersex people in population surveys can be difficult because individuals with differences of sex development may not refer to themselves as “intersex” or see intersex as a social identity (GenIUSS Group, 2014).2

This work highlights the need to understand more fully how current U.S. legal, social, and cultural shifts are affecting LGB people, their families, and their communities. There is a dearth of research on how transgender, non-binary, and intersex individuals are affected by changes to state and local policies.

In response to these challenges, the National Academies of Sciences, Engineering, and Medicine convened an ad hoc committee to explore what is currently known about lesbian, gay, bisexual, transgender, queer, and intersex populations—in families and in environments such as school, work, and civic groups; at the ballot box; and in legal and health care systems—and to identify the gaps in knowledge around their experiences and consider how their well-being might be enhanced with improved research across several different domains. This report is designed to describe the opportunities and challenges facing these populations and to offer recommendations about future research.

CHARGE TO THE COMMITTEE

The Committee on Understanding the Status and Well-Being of Sexual and Gender Diverse Populations, convened in 2019, was composed of expert professionals from many disciplines, including human development, psychology, sociology, demography, economics, law, medicine, public health, and gender and sexuality studies. They were asked to prepare a report examining the available data on and significant research needs relevant to persons of diverse sexualities and genders and persons with differences in sex development across multiple dimensions over the life course; see Box 1-1 for the complete statement of task.

Considered as a whole, the findings of this report are intended to describe the current status of sexual and gender diverse populations and to offer recommendations about ways in which research can be improved to advance the health and well-being of those populations. It builds not only on the 2011 report of the Institute of Medicine but also on previous studies and activities related to these populations; see Appendix A.

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2 Intersex people are individuals born with any of several variations in sex characteristics, including chromosomes, gonads, sex hormones, or genitals; see below for more information on why intersex individuals are included in this report.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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KEY TERMS AND DEFINITIONS

This report uses numerous terms to describe sexual and gender diverse groups of people, some which might be unfamiliar to some readers or which may have varying colloquial or contextual meanings. This section describes how the committee understands these terms and how they are used in this report.

Many studies we reference in this report refer to LGBT individuals. The first three terms—lesbian, gay, and bisexual—refer to sexual orientation, which is understood by researchers to have three distinct components: sexual attraction, sexual behavior, and self-identification. Sexual attraction refers to the gender(s) of the people to whom someone feels physically or romantically attracted. The delineation between sexual orientation and sexual attraction is often particularly important for people who may not be sexually active. Sexual behavior refers to the gender(s) of one’s sexual partners. Self-identification refers to how people describe their own sexual orientation.

Lesbian and gay are commonly used to refer to people whose attraction, behavior, and identities are oriented toward people of the same gender. Bisexual refers to people whose attraction, behavior, or both is toward people of both the same and different genders. Other terms that describe

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

sexual orientation include heterosexual or straight, which refer to people whose attraction and behavior are oriented toward people of a different gender; men who have sex with men (often referred to as MSM), which refers to men who may or may not identify as gay or bisexual but who have male sexual partners; and asexual, which refers to people who do not experience sexual attraction. People who are not heterosexual or straight may also identify using terms that reflect specific cultural or age groups. For example, same-gender-loving is often used in Black communities to describe non-heterosexual relationships, queer is more common among younger people as a description of non-binary or non-heterosexual identity, and Two Spirit is used in many Native American communities to denote the fluidity of gender.3

The term transgender refers to gender identity, which is distinct from sexual orientation. Transgender is a broad term that describes people who identify as a sex or gender different from the sex they were assigned at birth. For example, a transgender woman is a woman who was assigned male at birth, and a transgender man is a man who was assigned female at birth. Other terms, such as non-binary, agender, bigender, genderqueer, gender fluid, and gender-nonconforming, refer to people who identify outside the categories of male or female. People who embrace these identities may or may not identify as transgender. Some people also use the terms Two Spirit and queer to describe gender identity as well as sexual orientation. People who are not transgender are cisgender. Like cisgender people, transgender people can be of any sexual orientation.

Concepts and terminology related to sexual orientation and gender identity are constantly in flux. For instance, many community members and researchers now prefer to replace the acronym LGBT with LGBTQ, in which the Q may refer to queer or questioning, which is a particularly important concept for those on the path to developing or exploring an LGBTQ-related identity, especially in adolescence. In some contexts, the acronym is expanded further to include “I” for intersex, “A” for asexual or ally, or “+” as an acknowledgment of the diversity of non-binary and gender-nonconforming individuals. Other newer terms related to sexual orientation include monosexual, which means people who are attracted to only one gender, such as straight, gay, and lesbian people; non-monosexual, which describes people attracted to more than one gender (including bisexual people), and pansexual, which refers to people attracted to several genders.

Intersex and differences of sex development are terms that describe people born with primary or secondary sex characteristics that do not

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3 Two Spirit is also used in some Native American cultures to describe people who fulfill a traditional third-gender ceremonial role in their communities.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

fit binary medical definitions of male or female reproductive or sexual anatomy. Intersex traits are widely heterogeneous and include variations in number of sex chromosomes, structure or function of gonadal tissue, synthesis or action of sex hormones, appearance of external genitalia, and patterns of secondary sex traits. The prevalence of intersex traits ranges depending on the specific definition used. For instance, as few as 1 in 2,000–4,500 people are born with external genitals that lie somewhere between binary male or female genitalia, but as many as 17 in 1,000 people are born with any variation in their physical reproductive or sexual characteristics.

The language used to describe these traits, and the people born with them, is complex and shifting. For example, in recognition of leaps in understanding of the physiology of intersex traits, a consensus group of researchers and providers in 2006 developed the phrase “disorders of sex development” to replace what had been an inconsistent, confusing, and stigmatizing array of terms. Although some clinicians have suggested that use of the term “disorders” helps underscore serious health concerns that may accompany an intersex trait, others argue that “disorders” is stigmatizing and pathologizing. Increasingly, clinicians, researchers, and advocates have adopted the term differences of sex development (DSD). DSD is frequently used in medical literature, and some individuals find that this language offers the opportunity to identify as having, rather than being, a medical condition. Others, including most advocacy groups, prefer the less medical term, intersex or intersex traits.

In one clinical survey, intersex and differences of sex development were about equally preferable. Some advocates and providers are increasingly using the term endosex to describe people whose reproductive or secondary sex characteristics align with medical binaries, just as the term cisgender is used in parallel with the term transgender. Since people who describe themselves as LGBT or intersex are numerically minority populations in the United States, researchers thus sometimes describe these populations as sexual and gender minorities. The Sexual and Gender Minority Research Office at the National Institutes of Health defines sexual and gender minority populations as including, but not being limited to, “individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two Spirit, queer, and/or intersex. Individuals with same-sex or -gender attractions or behaviors and those with a difference in sex development are also included.”4 While in a research context the word “minority” points to the prevalence of a group within a population, in nonclinical contexts the word can carry a connotation of “lesser than” and can denote “a part of a population differing from others in some characteristics

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4 See https://grants.nih.gov/grants/guide/notice-files/NOT-OD-19-149.html.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

and often subjected to differential treatment.”5 As the community grows and becomes more diverse, the language that is used to refer to it will undoubtedly shift.

These and other terms will continue to evolve and take on different forms and meanings across different cultures and age groups, and it is important for researchers and other stakeholders working with these populations to be aware of and open to changing trends in terminology.

Just as there are different ways to think of sexual and gender diverse people, there are also different ways of describing the positions they occupy in society and the unique difficulties they may face because of their identity. Sociologist Erving Goffman (1963) defined stigma as an attribute, behavior, or reputation that is socially discrediting in a particular way. Societies generally apply value to certain normalized traits while devaluing others, such as sexual and gender diversity, and thereby assigning those people to an inferior social status. Sexual prejudice is another term to describe the negative view of sexual and gender diverse people held by individuals who have internalized the aforementioned social stigma.

Discrimination describes the negative treatment of sexual and gender diverse people compared to their heterosexual or cisgender counterparts. Discrimination can be interpersonal, such as denial of services based on sexual orientation or gender identity, and it can also be structural, such as laws or policies that systematically disadvantage sexual or gender diverse individuals in such areas as employment and education.

Even in the absence of active discrimination or recognizable social stigma, there are occasions in which sexual and gender diverse people do not have the same access to opportunities and achievement of outcomes as others. Inclusion, in this context, defines an individual’s access to opportunity and ability to fully participate in social institutions, such as the labor force, the health care system, and civic and political processes. Exclusion refers to situations in which sexual and gender diverse people do not have the same opportunities or access. Sometimes exclusion happens as a result of the way sexual and gender diverse people are relegated to less important positions in society or made to feel powerless against the mainstream—a phenomenon called marginalization.

Finally, the terms homophobia, biphobia, and transphobia refer to societal bias and internalized fear of LGBT people; they can denote the presence of stigma, prejudice, discrimination, or violence toward LGBT people, as well as a denial of access to opportunity.

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5 See https://www.merriam-webster.com/dictionary/minority.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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ADDRESSING THE CHARGE

Sexual and Gender Diverse Populations

As discussed above, contemporary understandings of sexual orientation and gender identity continue to evolve, as does the terminology used to describe individuals who do not align with the male-female dichotomy or who exhibit attractions to people of the same sex or outside of the traditional gender binary—a factor that complicates scholarly attempts to identify these populations for effective study. In this report, when discussing these populations at large, the phrase sexual and gender diverse (SGD) is used to acknowledge the broad spectrum of natural human variation in sexual orientation, gender identity, and sex development. Other designations or terms encompassing multiple population groups of SGD people—such as LGB, LGBT, LGBTQ, and others—are used when discussing data and evidence based on those specific designations.

The committee acknowledges that no term is perfect or completely inclusive; the beauty of individuality is that self-expression, as well as personal and romantic choices, can manifest in a multitude of ways. Furthermore, the intention is not to promote the phrase sexual and gender diverse (or SGD) as terminology for widespread use. Instead, the committee’s goal is to draw the attention of researchers, practitioners, policy makers, and society to the diversity of these groups and the need for greater understanding of differences that exist within and between them.

Inclusion of Intersex People

Little is known about the population health or well-being of people with intersex traits. The vast majority of research exploring the health of people with intersex traits is conducted in clinical samples. Intersex status is almost never queried in population surveys, and the stigma associated with having intersex traits may inhibit people from self-identifying. Moreover, because medical providers until recently did not routinely educate intersex patients about their traits, many people have limited awareness of their own medical history in this area. Fortunately, researchers and advocates have identified questions that can be used to assess intersex status in population surveys.

The medical impact of these traits varies widely and usually with the specific trait: for instance, people with congenital adrenal hyperplasia may require lifelong hormonal treatment for cortisol deficiency. Similarly, individuals with gonadal dysgenesis, who are born with gonads that do not produce hormones, are at markedly elevated risk of gonadal cancer and

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

may benefit from removal of gonadal tissue in early adolescence.6 As discussed in detail later in the report, however, there is an emerging body of knowledge documenting significant adverse consequences from irreversible interventions performed in early childhood primarily to align sex characteristics with gender assignment.

Understanding intersex as a medical problem might suggest that intersex populations should not be included in a report on the health and well-being of SGD populations, which are more commonly understood to be defined by non-normative identities. Indeed, not all people with intersex traits or DSD will identify as intersex; instead, they may identify as having a medical condition. Many people with intersex traits have cisgender experiences and identify as heterosexual. Moreover, some adults or parents of children with intersex traits may explicitly wish to distance themselves from SGD communities and any words that imply atypical gender or sexuality. There is also concern that simply adding “I” to the LGBTQ acronym may imply that intersex is monolithic, thereby obscuring the diversity of intersex-related health care needs and concerns of this population (Callens et al., 2012).

However, the committee found that there is sufficient overlap with other SGD populations to justify the inclusion of intersex in this report. First, many people with intersex traits do identify as non-heterosexual or non-cisgender, with evidence that the rates of non-heterosexuality and non-cisgender experiences are significantly higher than among endosex populations (Almasri et al., 2018). People with intersex traits/DSD were identified as a health disparity population by NIH, as well as by the American Association of Medical Colleges; both of these groups noted that intersex people may experience difficulties in accessing expert medical and psychosocial care similar to those encountered by SGD people.

Intersex health disparities appear to be driven in large part by the medical approach to intersex traits, which has been informed by the same stigmas experienced by SGD populations. Starting in the 1950s, infants born with intersex traits were exposed to medical and surgical interventions to align their anatomy with male or female (endosex) anatomy, with the explicit goal of rearing a cisgender, heterosexual child. Surgical decision making was often driven by the priority of creating genitals capable of penovaginal intercourse. Fearful that children might otherwise question their gender or sexuality, diagnostic information was routinely withheld from children and often even from their families. This model of care has reinforced cultural stigmas around sex and gender atypicality in an attempt to ensure sex and gender normalization (Dreger, 1998).

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6 A full account of the medical and surgical support of specific intersex traits is far beyond the scope of this report; Chapter 12 provides additional information.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

Still today, a desire to avoid the stigma of a non-normative sexual body is a stated goal of genital surgery for intersex children (see discussion in Chapter 12). Accordingly, intersex advocates have drawn parallels between normalizing genital surgery and sexuality and gender identity conversion therapy. However, little research has explored the effects of stigma within intersex populations.

Finally, while the committee recognizes the risk of obfuscating the unique individualities of intersex bodies, it also acknowledges that recent SGD research has illuminated the diversity of those populations. Just as research on the health of men who have sex with men validates and reinforces the difference between sexual identity and behavior, transgender health research has illuminated the spectrum of affirming medical and surgical procedures. It well may be that disparities in health and well-being among the intersex population are wholly distinct from those of other SGD populations, but given the intersections with SGD experiences and the absence of robust intersex population health research, it is difficult to justify the exclusion of intersex populations from our study.

Understanding Well-Being

The concept of well-being embodies both how people feel and how they function. The way a person feels is informed by the person’s physical health, mental health, and emotions (e.g., happiness, contentment, anger), as well as personal judgments about one’s life (e.g., purpose and satisfaction); the way a person functions, on both personal and social levels, incorporates such elements as sense of competency, agency and ability to act autonomously, and sense of being connected to others (New Economics Foundation, 2012). As health is a key component to well-being, so is well-being to health; the two concepts are closely related regarding states of human existence. The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1948). The concepts of well-being and health will be explored in this report with respect to sexual and gender diverse populations.

The determinants of health and well-being for every sexual and gender diverse individual vary over the course of a lifetime (life course) and include factors related to each person, people (social spheres of influence), and the environment (social systems). Person-level factors include contributors to identity such as age, race, ethnicity, military status, disability, socioeconomic position, and involvement in the criminal justice system. People-level factors are a person’s social spheres of influence, meaning peers, family, social networks, and community. Environmental-level determinants of health and well-being are related to the structures, processes, and behaviors of societal systems, sectors, and institutions (or agents) toward sexual and

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

gender diverse people. Together, these determinants interact with one another in ways that can intensify or ameliorate barriers to good health and a positive sense of well-being. For example, an SGD youth who experiences bullying and physical violence from classmates in a school system that lacks policies, training, and practices to prevent and address these behaviors may later struggle with depression, anxiety, self-injury, suicide attempts, and other physical and mental health conditions, but avoid seeking health care because of prior experiences with stigma and discrimination in the health care delivery system. These three elements—personal identities, social spheres of influence, and interacting societal systems—and other core frameworks are further developed in Chapter 2.

In this report the committee focuses on eight domains of well-being: the effects of various laws and the legal system on SGD populations; the effects of various public policies and structural stigma; community and civic engagement; families and social relationships; education, including school climate and level of attainment; economic experiences (e.g., employment, compensation, and housing); physical and mental health; and health care access and gender-affirming interventions.

People with different sexual orientations and gender identities have different experiences in each of these domains over the course of their lives. For example, one study found that in the labor market, gay men face a large negative wage gap, lesbian women earn higher wages than similarly situated heterosexual women, and bisexual men and women appear to be the most economically disadvantaged (Mize, 2016). Other studies show that transgender people face higher rates of discrimination and poverty than LGB people. Furthermore, when considering the opportunities and disadvantages for SGD individuals in each domain, one must also acknowledge intersectionality of identities—conditions that, when combined, can create unique outcomes for individuals. Those intersections include race and ethnicity, age, military status, incarceration, disability, and the ways in which the person is perceived by others. Frameworks such as these can yield important variations both within and across SGD groups (Goldberg and Conron, 2018).7

COMMITTEE’S APPROACH TO THE STUDY

The committee took a multipronged approach toward gathering and analyzing the necessary evidence for its work. In addition to reviewing published literature, the committee also heard testimony from relevant experts in a variety of topic areas and held a number of open-session conversations to engage in person with stakeholders and community leaders.

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7 Intersectionality and other frameworks are discussed further in Chapter 2.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

At the first meeting, the committee heard from the report’s sponsors in order to get a clear sense of the goals of this project: David Adler of the Robert Wood Johnson Foundation; Karen Parker of the Sexual and Gender Minority Research Office at the National Institutes of Health; Darwin Thompson of Gilead Foundation; and Kika Chatterjee, Szena Dayo, and Faiza Riaz of the Tegan and Sara Foundation all shared with the committee their organizations’ priorities for this work. At that same meeting, the committee also heard from Cecilia Chung of the Transgender Law Center, Ellen Kahn of the Human Rights Campaign, and Sandy James of FreeState Justice8 in an attempt to better understand the potential value and utility of this report for the communities to whom it pertains. Additionally, committee members Angelique Harris and Stephen Russell briefed attendees on the content and findings of two meetings held in 2018 and 2019 at the National Academies of Sciences, Engineering, and Medicine that helped to lay the foundation for this consensus study (see Appendix A).

At the second in-person committee meeting, the committee organized a large public seminar in order to engage this project’s relevant constituent communities. The committee held panels on culture, representation, and community frameworks; intersex individuals and families; non-binary and plurisexual9 identities; sexual and gender diversity law and policy; and civic engagement. See the agenda for this seminar in Appendix B. In its closed meetings, the committee reviewed multiple sources of evidence, evaluated the methodologies of research studies, and discussed possible interpretations. Throughout these deliberative processes, committee members were asked to apply their expertise in their respective fields. In addition to its four in-person meetings, the committee held two online meetings to ensure sufficient discussion and to advance progress on the study.

METHODS AND APPROACH TO THE EVALUATION OF EVIDENCE

This report draws on evidence from a number of sources of empirical research on SGD populations. One important dimension of these sources is the crossing of disciplinary boundaries. Because of the broad focus of its charge, the committee reviewed the relevant bodies of knowledge from a number of academic disciplines—public health, medicine, psychology, economics, sociology, gender studies, history, law, demography, and political science—along with interdisciplinary fields, such as African American studies, each of which has different standards of evidence. Over the last few decades, research on SGD populations has expanded in each of these disciplines and fields, pro-

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8 James is now working at the U.S. Department of Health and Human Services.

9 The term “plurisexual” is used to describe individuals who are attracted to more than one gender.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

viding a basis for understanding more about the lives of people of diverse sexualities, genders, and with differences in sex development.

The committee sought out research published in peer-reviewed academic publications (journals and books) and supplemented that with research from other sources, such as government agencies, nongovernmental organizations, and think tanks. The committee also took care to ensure that for each area of focus, the work engaged with the lived experience of individuals representing SGD populations: because of the deeply personal nature of this work, the committee centered the expert testimony of members of the communities affected by the results of this work. In all cases, the committee evaluated how effectively the research adhered to broadly accepted research norms, such as whether a study included an adequate reporting of data, methods, and analysis to allow assessment of the quality and accuracy of the conclusions drawn by the authors. Those foundations provided a basis for judgments and conclusions about what is known about SGD populations.

In terms of the published literature, the committee believes it is critical to draw particular attention to three general methodological considerations that affect the conclusions that can be drawn from existing research: the nature of the data and samples used; the research designs used; and the use of sources other than survey or experimental data for the study of some areas. Much of the research reviewed for this report has been made possible by the inclusion of questions about sexual orientation and gender identity in surveys of probability samples of the U.S. population (see Chapter 4 for a list of those surveys). Data generated by probability-based sampling methods are likely to be representative of the populations and subgroups in question, allowing generalizations to be made from those samples. That representativeness is essential for making comparisons across diverse sexual and gender populations in order to, e.g., compare rates of a particular health condition among lesbian, gay, and bisexual people to that of heterosexual people or to compare transgender people to cisgender people.

However, the fact that the SGD populations studied in this report, such as lesbian, gay, bisexual, transgender, and intersex people, are relatively small means that only large samples of the whole population will include sizable numbers of people in sexual and gender diverse groups as usually defined. This situation has a number of consequences for researchers, such as limiting the ability to use probability samples for comparisons of detailed racial, ethnic, age, or geographic groups of LGBT people, for example, or to study in detail rare health or economic outcomes. In addition, the underlying surveys are not likely to have questions that relate to important aspects of SGD people’s lives, even when the surveys capture sexual and gender diversity for respondents, unless the questions also happen to be relevant for the lives of the population at large.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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Partly because of such limitations, studies using non-probability-based sampling methods, such as community recruitment or snowball sampling, are common in many disciplines and can provide important insights. In this report, the committee exercised care in interpreting the relevance of findings from such samples to apply to the broader SGD population. For example, clinical studies might involve samples of individuals with poorer health who are not representative of the larger population. Convenience sampling techniques might result in biases toward certain groups, such as those with higher-than-average levels of income or education. Administrative datasets, such as health insurance claims or discrimination charge filings, reduce concerns about sampling bias but still require an assessment of who had access to the services that resulted in the creation of the administrative records.

The second important consideration is research design. The committee acknowledges that all research designs have strengths and weaknesses for answering the questions defined in its statement of task. Many studies reviewed for this report are observational studies—that is, those studies made comparisons based on observed differences in sexual orientation or gender identity in a sample, usually holding other observed characteristics constant. This general approach is appropriate for assessing whether there is a statistical association between being a member of a sexual or gender diverse group and a specific health, economic, or other social outcome. However, drawing a causal conclusion about whether and how having an SGD status or identity affects a research outcome is difficult because of the ways in which unobserved characteristics could vary by groups or by individuals and therefore affect outcomes. For example, the wage gap between lesbian and heterosexual women could be a byproduct of lesbian women having more labor market experience, but there is a lack of data on that particular issue.

Another issue for many studies is that they are cross-sectional, focusing on data collected on individuals at only one point in time. Thus, it may not be possible to know when a variable of interest—such as an experience of stigma—occurred in relation to the outcome being studied. Longitudinal surveys that collect data on the same people over time can help with both issues, allowing researchers to assess the role of personal characteristics and to examine whether changes in important variables are associated with changes in outcomes. Though they have increased in recent years, such datasets are still rare in research on SGD populations.

Experimental research methods are designed to allow more conclusive assessments of causal connections, since an exposure or intervention is varied randomly across groups and researchers then test for differences in outcomes by group. However, there are limitations in the application of those methods to the issues of interest in this report. In particular, it is

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
×

obviously not possible to randomly assign a particular sexual orientation or gender identity to individual people, or to randomly assign an experience of stigma, and then to compare outcomes across groups. Some studies have used experimental and quasi-experimental methods to answer other questions about the effects of policies, interventions, or other possible experiences of SGD populations. Since those policies or other conditions are different across time and place, researchers can study whether particular effects are present or are stronger in those places that are “treated” by a particular policy than in those places without the “treatment.”

The third issue concerns research that is rooted in methods other than surveys or experiments, as referenced particularly in the chapters on communities, law, and public policy. Some of the research on development of communities draws on ethnographic and historical research methods. Such studies may involve archival research, observations, interviews, or the analysis of cultural phenomena (e.g., art, literature, and film). The chapters on law and public policy include some studies using quantitative methods, but they also include the review of case law, statutes, and legal institutions, as well as legal scholarship.

Given the above considerations and the varying sources of the findings discussed in this report, wherever possible the committee sought findings that are consistent across different datasets and research methods—an established procedure for assessing validity (Campbell and Fiske, 1959). The committee also notes strengths and weaknesses of various research methods described in this report.

Lastly, when reviewing many studies, including those that demonstrate an adherence to scientific rigor, the committee was frequently reminded that the heteronormativity of common research designs (collecting data on males, females, and heterosexual relationships; not accounting for alternate identities and romantic relationships) may not enable data collection that provides detail on less prominent SGD groups or characteristics. When pertinent data do not exist or are not presented in ways that advance the understanding of SGD populations, the committee makes recommendations on how to collect new data or to analyze existing data in ways that could advance that understanding.

REFERENCES

Almasri, J., Zaiem, F., Rodriguez-Gutierrez, R., Tamhane, S.U., Iqbal, A.M., Prokop, L., Speiser, P.W., Baskin, L.S., Bancos, I., and Murad, M.H. (2018). Genital reconstructive surgery in females with congenital adrenal hyperplasia: A systematic review and meta-analysis. Journal of Clinical Endocrinology and Metabolism, 103(11), 4089–4096. doi: 10.1210/jc.2018-01863.

Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2020. Understanding the Well-Being of LGBTQI+ Populations. Washington, DC: The National Academies Press. doi: 10.17226/25877.
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Callens, N., van der Zwan, Y.G., Drop, S.L.S., Cools, M., Beerendonk, C.M., Wolffenbuttel, K.P., and Dessens, A.B. (2012). Do surgical interventions influence psychosexual and cosmetic outcomes in women with disorders of sex development? ISRN Endocrinology, 2012, 1–8. doi: 10.5402/2012/276742.

Campbell, D.T., and Fiske, D.W. (1959). Convergent and discriminant validation by the multitrait-multimethod matrix. Psychological Bulletin, 56, 81–105.

Dreger, A.D. (1998). A history of intersexuality: From the age of gonads to the age of consent. Journal of Clinical Ethics, 9(4), 345–355.

Fish, J.N., Watson, R.J., Porta, C.M., Russell, S.T., and Saewyc, E.M. (2017). Are alcohol-related disparities between sexual minority and heterosexual youth decreasing? Addiction, 112(11), 1931–1941. doi: 10.1111/add.13896.

Gallup. (2018). Gay and Lesbian Rights. Available: http://news.gallup.com/poll/1651/gaylesbian-rights.aspx.

GenIUSS Group. (2014). Executive summary. In J.L. Herman (Ed.), Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population-Based Surveys. Los Angeles, CA: Williams Institute.

Goffman, E. (1963). Stigma. Alexandria, VA: Alexander Street Press.

Goldberg, S.K. and Conron, K.J. (2018). Demographic characteristics of lesbian, gay, bisexual, and transgender adults in the United States: Evidence from the 2015–2017 Gallup Daily Tracking survey. In W. Swan, (Ed.), The Routledge Handbook of L.G.B.T.Q. Administration and Policy. New York: Routledge.

Hatzenbuehler, M.L. (2016). Structural stigma: Research evidence and implications for psychological science. American Psychologist, 71, 742–751.

Institute of Medicine. (2011). The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: The National Academies Press. doi: 10.17226/13128.

Mize, T.D. (2016). Sexual orientation in the labor market. American Sociological Review, 81(6), 1132–1160.

New Economics Foundation. (2012). Measuring Well-being: A Guide for Practitioners. London: Centre for Well-Being, New Economics Foundation. Available: https://b.3cdn.net/nefoundation/8d92cf44e70b3d16e6_rgm6bpd3i.pdf.

Pew Research Center. (2017). Changing Attitudes on Gay Marriage. Available: http://www.pewforum.org/fact-sheet/changing-attitudes-on-gay-marriage.

Toomey, R.B., and Russell, S.T. (2013). The role of sexual orientation in school-based victimization: A meta-analysis. Youth and Society, 48(2), 176–201.

World Health Organization. (1946). Preamble to the Constitution of the World Health Organization. Official Records of the World Health Organization. Available: https://www.who.int/governance/eb/who_constitution_en.pdf.

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

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

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

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