Understanding the Well-Being of LGBTQI+ Populations (2020) / Chapter Skim
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11 Physical and Mental Health
11 Physical and Mental Health
Pages 287-348
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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.
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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.
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. 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)
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. 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)
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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.
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. 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.
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. 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.
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. 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)
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. 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)
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, 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.
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. 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)
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. 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.
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. 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)
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. 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.)
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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)
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. The study of sexual function among transgender people has focused on genital sensation after gender-affirming surgeries (Frey et al., 2017)
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. 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)
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. 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)
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. 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)
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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)
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. 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)
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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)
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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)
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. 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.
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. 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)
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. 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)
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. 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)
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Another study using NESARCIII 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)
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. 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)
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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.
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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.
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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. CONCLUSION 11-3: The physical and mental health disparities expe rienced by sexual and gender diverse populations are driven by social forces, such as stigma, prejudice, and discrimination; they are not intrinsic personal characteristics related to sexual orientation, gender identity, or intersex status.
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. Sexual orientation, treatment utilization, and barriers for alcohol related problems: Findings from a nationally representative sample. Drug and Alcohol Dependence, 161, 323–330. doi: 10.1016/j.drugalcdep.2016.02.025.
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. Smoking cessation programs for lesbian, gay, bi sexual, transgender, and intersex people: A content-based systematic review.
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. Adult health behaviors over the life course by sexual orientation.
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. Sexual orientation differences in modifiable risk factors for cardiovascular disease and cardiovascular disease diagnoses in men.
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. Sexual violence, stalking, and intimate partner violence by sexual orientation, United States.
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. On hate crime victimization: Rates, types, and links with suicide risk among sexual orientation minority special interest group members.
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. Bridging barriers to cervical cancer screening in transgender men: A scoping review. American Journal of Men's Health, 14(3)
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. Physical health disparities across dimensions of sexual orientation, race/ethnicity, and sex: Evidence for increased risk among bisexual adults.
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. Associations between sexual orientation discrimination and substance use disorders: Differences by age in US adults. Social Psychiatry and Psychiatric Epidemiology, 55(1)
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. Minority stress, smoking patterns, and cessation attempts: Findings from a community-sample of transgender women in the San Francisco Bay Area.
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. Health disparities by sexual orientation: Results and implications from the behavioral risk factor surveillance system. Journal of Com munity Health, 42(6)
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. Social networks and sexual orientation disparities in tobacco and alcohol use.
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. Lifetime preva lence of suicide attempts among sexual minority adults by study sampling strategies: A systematic review and meta-analysis. American Journal of Public Health, 106(5)
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. Sexual orientation and gender identity disparities in sub stance use disorders during young adulthood in a United States longitudinal cohort. Drug and Alcohol Dependence, 205, 107619.
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. Associations of bisexual-specific minor ity stress and health among cisgender and transgender adults with bisexual orientation.
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. Sexual orientation disparities in sub stance use: Investigating social stress mechanisms in a national sample.
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. Social stress and substance use disparities by sexual orientation among high school students.
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. Sexual orientation and sub stance abuse treatment utilization in the United States: Results from a national survey.
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. Sexual orientation, minority stress, social norms, and substance use among racially diverse adolescents.
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. Increased rates of smoking cessation observed among transgender women receiving hormone treatment. Endocrine Practice, 23(1)
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. Intimate partner violence in transgender populations: Systematic review and meta-analysis of prevalence and correlates. American Journal of Public Health, 110(9)
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. Comparing receipt of cervical cancer screening and completion of human papillomavirus vaccination using a new con struct of sexual orientation: A serial cross-sectional study. LGBT Health, 6(4)
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. The Transgender Women of Color Initiative: Implementing and evaluating innovative interventions to enhance engagement and reten tion in HIV Care. American Journal of Public Health, 107(2)
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. Sexual orientation disparities in cancer-related risk behaviors of tobacco, alcohol, sexual behaviors, and diet and physical activity: Pooled Youth Risk Behavior Surveys.
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. HIV testing and PrEP use in a national probability sample of sexually active transgender people in the United States. Journal of Acquired Immune Deficiency Syndromes, 84(5)
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. Prevalence of sexually transmitted infections and bacte rial vaginosis among lesbian women: Systematic review and recommendations to improve care. Cadernos de Saude Publica, 35(3)
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. Gender identity, sexual orientation, mental health, and bullying as predictors of partner violence in a representative sample of youth.
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. Sexual orientation and health among U.S.
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. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study)
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