Thomas Lawrence Long, Christine Rodriguez, Marianne Snyder, & Ryan Watson
Decades of research have indicated that LGBTQ populations face a disproportionate burden of health problems and stigma in our society, including higher levels of depression, lower self-esteem, compromised academic achievement, and more substance use (Fredriksen-Goldsen et al., 2013; Institute of Medicine, 2011; Reisner et al., 2014; Russell & Fish, 2016). These disparities are documented across the lifespan, from childhood (Kosciw, Palmer, & Kull, 2015), to young adulthood (Ryan et al., 2010; Watson, Veale, & Saewyc, 2017), and even into late adulthood (Fredriksen-Goldsen, 2014). Researchers have identified minority stress, or sexuality- and gender-related stressors (Meyer, 2003) as the mechanism through which these health problems can be explained.
Minority Stress Model
Being a marginalized or minority person in a society produces personal and group stress, sometimes invisible but always with both psychological and physiological effects. The IOM (2011) report proposed the minority stress model as a strong framework to understand health disparities among LGBTQ populations. In particular, the report highlights how minority stress has been found to affect the day-to-day lives and health of LGBTQ individuals across the lifespan. This minority stress can be distal (e.g., victimization from others because of a sexual minority identity) or proximal (e.g., concealment of sexual identity, internalized homophobia). Therefore, strategies to promote health and well-being should consider multiple types of stressors.
In addition to minority stress, the IOM (2011) recommended a focus on intersectionality as an imperative consideration for researchers, clinicians, and other stakeholders invested in LGBTQ health. Intersectionality at its broadest meaning proposes that race, ethnicity, ability/disability, and other oppressed identities can amplify LGBTQ health issues (Parent, DeBlaere, & Moradi, 2013). In addition to being aware how oppressed and intersecting identities can compound health outcomes, researchers are increasingly measuring and considering all demographic characteristics among LGBTQ youth to better understand how multiple identities (e.g., being Black, gay, and residing in the American South) might be related to the holistic LGBTQ experience. For example, Watson and colleagues (in press) collected data from 17,112 LGBTQ youth across the United States and documented 26 distinct sexual and gender identities. Additionally, youth who were transgender and non-binary were more likely than cisgender youth to identify with an “emerging sexual identity label,” such as pansexual. These patterns also differed by ethnoracial identity, suggesting that youth of color are using different terms, compared to their White counterparts, to describe their sexual attractions and gender identities. The next step is to better understand how intersecting identities may be uniquely associated with health outcomes, given that a large focus of research has focused on disease prevention and health promotion among LGBTQ populations. The Institute of Medicine (2011) also points out that LGBTQ couples and their children are less likely to have adequate health insurance, which is usually provided through employers, especially when they are unemployed or under-employed.
Disease Prevention and Health Promotion
Recent research on health disparities finds that the gap in disparities between some LGBTQ and heterosexual youth continues to grow across a number of outcomes (e.g., Watson, Lewis, Fish, & Goodenow, 2018). Emerging research has moved beyond documenting these disparities to examining the risk and protective factors that may help prevent disease and promote health among LGBTQ people.
In respect to LGBTQ youth, research has consistently documented family and parent support to be the strongest buffer against negative health experiences, above and beyond other support systems (Snapp et al., 2016). In addition to families, a number of other support systems are known to protect against negative health (and thus later life disease), such as school-based clubs (Poteat et al., 2015), supportive peers (Watson et al., 2019), and supportive policies and laws (Hatzenbuehler, Keyes, & Hasin, 2009). The protective role of these support systems extends into young adulthood and across one’s lifespan, but the magnitude by which certain supports (e.g., school peers) impact LGBTQ health may change.
Among older LGBTQ adults, there has been a strong focus on STD and HIV prevention. Given HIV’s disproportionate burdens on the LGBTQ community, in particular African American men who have sex with men (Mays, Cochran, & Zamudio, 2004), research funding and attention have focused on reducing this stark disparity. Medical advancements in preventing HIV have proliferated in the recent past, and one method in particular, pre-exposure prophylaxis (PrEP), has been the focus of many studies (Golub et al., 2013; Kirby & Thornber-Dunwell, 2014). However, a vexing dilemma exists: although there is a drug that can prevent HIV infection, why aren’t more men who have sex with men (and LGBTQ individuals) taking the drug? After all, Kirby and Thornber-Dunwell (2014) find that the rates of HIV acquisition in the US are still high and similar to the rates in other countries. Researchers continue to consider how stigma, a history of medical mistrust, and other factors might thwart the uptake of life saving drugs that prevent HIV among LGBTQ populations (Parsons et al., 2017).
See Table 1 below for a summary of the critical health concerns at each stage of adult life.
Table 1. Health Concerns Across the Lifespan
|Life Stage||Health Concerns|
|Adolescence||HIV infection, particularly among Black or Latino men who have sex with men; depression, suicidal ideation, suicide attempts; smoking, alcohol, substance use; homelessness; violence, bullying, and harassment.|
|Early to Mid-Adulthood||Mood and anxiety disorders; using preventive health resources less frequently; smoking, alcohol, substance use.|
|Later Adulthood||Long-term hormone use among transgender people; HIV infection; stigma, discrimination, violence in health care institutions (e.g., nursing homes).
The research literature also suggests that older LGBTQ adults may possess a high degree of resilience, having weathered the difficulties of adolescence and earlier adulthood.
Source: IOM (2011)
A long history of health professionals’ insensitivity or even hostility to LGBTQ people, as we described in the beginning of this chapter, continues to have real life consequences. Disparities are particularly evident among transgender people who are a uniquely vulnerable population, and whose health and wellness concerns we discuss next.